Information to assist with Assessment,

Child Protection Enquiries and Conferences

URGENT & STRICTLY CONFIDENTIAL

Child’s Name:
(Include any other names the child has been known by) / Date of Birth: / Address:
Family Member/s: / Relationship to child: / Date of Birth: / Address:

Concerns have been expressed about the welfare of the child you have been contacted about (please complete details above if not already populated). Children’s Social Care are undertaking enquiries in relation to the child/ren in order toestablish if the concerns are substantiatedand if so, to decide whether to proceed to a section 47 enquiry /child protection (CP) conference. This is an initial request for information, therefore, completion of this form is considered an ‘essential service’ and there is no payment for completing it. GPs should be aware that the child’s (children’s) welfare takes precedent over issues of confidentiality to other members of the family.

Please also note that on completion of any initial enquires, if the concerns are progressed to a child protection conference, the information you provide will be shared at a multi-agency conference, including with parents / carers at the CP conference. If you do not wish the information to be shared with the parents/carers please indicate this clearly in section 15 of this form along with your rationale.

To assist with the sharing of information in respect of the child(ren) and their parents/carers, Children’s Social Care request that the following information is completed and returned to the address on the page overleaf within 5 working days. On occasions, you may be asked to return information sooner than 5 days dependent on the case, and your understanding and cooperation with such requests is greatly appreciated and invaluable.

Depending on the outcome of the assessmentsundertaken byChildren’s Social Care, you may be asked for information at three points in the CP process:

  1. Child and Family Assessment
  2. Ahead of a Child protection strategy meeting
  3. Initial CP conference

If you have previously provided information either by telephone or as part of these enquiries, please ensure you clarify whether there are no changes to your original information, or if new concerns have been identified in between submissions, these are clearly identified for the social care team and/or the Conference and Review Service.

In view of the tight deadlines, it may be necessary for another doctor in the practice to complete this form on your behalf.

1. / Are you the named GP for the child named above?Yes/No / Yes/No
2. / If you are not the named GP, do you have full access to the GP’s clinical records? / Yes/No
3. / How long has the child been registered with this surgery?
4. / Has the child/ren / family been previously registered with another surgery?
Details: / Yes/No
5. / If you have access to the clinical records, how many hospital attendances have there been in the last 2 years (or if since birth, if less than 2 years):
A&E: / No of attendances and reason:
Outpatients: / No of attendances and reason
Acute admissions: / No of attendances and reason
Out of hours: / No of attendances and reason
Other: / No of attendances and reason
6. / Have there been appointments / times when the child/ren has not attended?
Details: / Yes/No
7. / How many attendances at the GP surgery has there been in the last two years (or since birth if less than 2 years) including DNAs? (Include DNAs for immunisations).
When was the child last seen at the GP surgery and reason?
8. / Please comment on the following where possible:
Child’s general health:
Past history:
Birth history:
Developmental status:
9. / Have you ever had concerns about the safety of the child/ren listed above or is there any evidence of concern in the clinical records? Yes/No
If ‘yes’ please include details of any behaviours of concern and/or concerns about presentation, relationship problems etc. (Remember, categories of abuse include physical, sexual, emotional and neglect).
10. / Have you ever had concerns about unexplained symptomatology or is there any evidence in the records of concerns about unexplained symptomatology?
Details: / Yes/No
11. / Do you have any concerns related to potential fabricated or induced illness?
Comments: / Yes/No
12. / Do you have any concerns which have not been highlighted above, which may impact on the child’s safety and well-being?
Details: / Yes/No
13. / Do you have any concerns about Please tick relevant box
Child Sexual Exploitation □
Trafficking Human Beings □
Slavery □
13. / In respect of a parent or family member, are there any factors or evidence to suggest that any of the following may impact on the child’s safety or well-being or impact on parenting capacity (please tick):
  • Mental health, alcohol or substance misuse 
  • Domestic violence/abuse
  • Chronic illness
  • Disability 
  • A history of crime (particularly violent crime)
Comments:
(Please state the relationship of the family member with the problems to the child in question)
14. / From the information available to you, do you consider the risks to this child to be:
High Medium Low Don’t know? (Please circle)
Please state your reasons for your assessment of risk:
15. / Are you willing for the information contained within this report to be shared with parents/carers/other family members?
Comments: / Yes/No
16. / Have you previously supplied information regarding this child as part of this CP process?
Date supplied:
Are there any new concerns since your last submission of information?
Comments: / Yes/No

Name of GP completing the report (practice stamp)

Signature:Date:

Contact number for queries:

Please return this form to: (Name of social worker)…………………………………………………...

At:(Address of Children’s Social Care)

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Email: (secure address only)………………………………………………………………………………