Form 2: Initial Assessment Form

Form 2A: WellbeingObservations and Assessment

Child/Young Person’s Name
Date of Birth
CHI Number
Date of Assessment
Named Person / Contact Details / Agency

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Reason for completion:

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In this section please describe the main concerns about the child / young person’s mental health difficulties.

Name and Contact Details of person(s) completing form:

Name / Designation / Contact Details / Date

Having a mental health difficulty can impact on any of the wellbeing indicators below. When you are completing this form you can help us to make a decision on whether we proceed to assessment by considering the questions detailed in the different sections. Can you also please avoid using mental health terms e.g. “depression” or “anxiety” to describe worrying behaviours and provide observations.

Description of Child/Young Person’s Wellbeing

Is there anything getting in the way of this child/young person’s wellbeing?:
(Include evidence of strengths and concerns within each relevant domain)

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Safe
-Are there concerns about the child’s safety?
-Is the parent able to keep the child safe?
-How are relationships at home?
-Is the child being bullied at school?
-Is the child’s behaviour putting them at risk-how long, frequency, duration, severity etc?
-Does the child have a secure base?

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Healthy
-Is there any significant physical or mental health history?
-Is there any significant parental physical or mental health history?
-Describe your concerns about the child’s mental health and how these impact on him/her?

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Achieving
-Does the child’s mental health difficulties have an impact on aspects of their learning and development?
-Is the child developing as expected for their age?

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Nurtured
-Are there any concerns about attachment-please describe?

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Active
-Is the child’s mental health difficulties impacting on the child’s ability to play with others?
-How does the child interact and play with toys and others?
-Does the child attend clubs/have hobbies?

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Respected
-Is the child able to make his wants, needs and views known?
-Are carers and professionals able to use appropriate strategies to facilitate the child making his wants, needs and views known?

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Responsible
-Is the child’s mental health difficultiesimpacting on the child’s ability to play an active and responsible role?
-Have strategies already been put in place and if so have they helped?

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Included:
-Is the family able to include the child in a range of day to day activities e.g.trip to the cinema, supermarket, café?
-Do the child’s difficulties have an impact on the family’s day to day living?
-Can the child actively participate in school life with the appropriate supports?

Risk and Protective Factors (use resilience matrix and toolkit)

Summarise the impacts of the child’s SLC needs on the child / young person and their family.

What are the risks to the child/young person?

Identify any risks from the child/young person?

What protective factors and strengths, if any, support the child/young person’s resilience?

Is the child receiving any additional support from other services?

What things have you already tried to help the child manage better and what has helped?

Date child/young person last seen, where and by whom

3.The following discussions/actions have taken place to date:-

Helpful to include any TAC minutes and child and young person’s action plan

4.The child/young person has the following views about thisassessment:

5.The parents/carers have the following views about thisassessment:

6.Desired outcomes identified with the family

What are you hoping the speech and language therapist will help you to do to help the child better?

What are you hoping will have improved for the child?

7.Next Steps/Recommendations

A request for support from speech and language therapy may result in:

-Reassurance

-Sign posting to a more relevant source of help

-Advice

-Assessment

8.Contributors to Assessment

Name / Designation / Contact Details

9.Forwarded to:

Name / Designation / Contact Details / Date

10. Signature:Date:

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