Section 1: Child, Young Person and Family Details

Signs of Well-being Assessment and Planning Form

Section 1: Child, Young Person and Family Details

1A- About the Child/Young Person

Name:
D.O.B or estimated delivery date: / Home Address (inc postcode:
Age: / M/F/unborn:
Ethnicity: / First Language: / Telephone/Contact Details:

1B- About the Principal Parents/Main Carers

Name / Date of Birth / Relationship / Contract Details / Parental Responsibility Y/N

1C- About the Child/Young Person's Family/Household

Name / Date of Birth / Relationship / Contract Details / Parental Responsibility Y/N

Section 2: Key Agencies

Please detail any professionals know to be working with the child/young person/family

Agency / Name / Contract Details

Section 3: Consent

3a- Consent for the referral3B- Consent for the sharing of information with other agencies

Is the Child/Young Person aware of the referral? / Yes / No / / have read the contents of this form and agree to information being shared with other agencies, family members and friends as part of the FGC process:
Are the Parents/Carers aware of the referral? / Yes / No / Name of Child/Young Person:
Has the Child/YP given consent for this referral? / Yes / No / Signature: / Date:
If NO please state reasons / Name of Parent/Main Carer:
Signature: / Date:
Have the Parents/Carers given consent for this referral? / Yes / No / Has this form been copied to child/young person? / Yes / No
If NO please state reasons / Has this form been copied to parents/carer? / Yes / No

Section 4: Practitioner Completing Assessment

Practitioner Details:

Name / Title / Agency / Contract Details
Possible date/time Professional Available for FGC?
What is the “bottom line”? ”? i.e. what would you have to insist upon for the plan to be deemed safe? Would failure to meet the bottom line result in statutory action?

Date Completed:

Worries
What is happening with the child that is worrying you? Current Situation (is child on CP/Section 20/ICOetc) / Family Strengths / Dynamics and Resources
What relevant resources and strengths are already in place? Potential Risks?
Child/Young Persons Views/ Goals
What does the child/young person want to change and what are their ideas for achieving this? (Wish List) / Carers / Parents Views Goals
What do the carers want to change and what are their ideas for achieving this? / Professionals Goals
What changes do the professionals need to see to be confident about the child's well-being? Are there any timescales to consider?
Well-being Scale
Given the above information, rate the childs well-being on a scale of 0-10
0 = your worries about the child/young person are bound to continue 10 = the child/young person is doing well enough that no extra professional involvement is required. / Rating / Service User Evaluation
Rate this completed form on a scale of 0-10.
0 = this has not captured what you have said,
W = this completely captured what you have said / Rating

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