FORM-PKS Welfare Visit Referral - Please complete all sections of this form

Please complete all sections of this form

Please confirm this is the form you require PKS WELFARE CHECK REFERRAL or close this tab to return to the form selection screen.

Please provide details of all children/young people being referred

Local Authority ID Number

Gender/Identifies as (pronoun)

Forename

Ethnicity

Surname

Religion

Date of birth

Language

2nd Child /Young person

2nd Child /Young person Local Authority ID Number

2nd Child /Young person Gender/Identifies as (pronoun)

2nd Child /Young person Forename

2nd Child /Young person Ethnicity

2nd Child /Young person Surname

2nd Child /Young person Religion

2nd Child /Young person Date of birth

2nd Child /Young person Language

3rd Child /Young person

3rd Child /Young person Local Authority ID Number

3rd Child /Young person Gender/Identifies as (pronoun)

3rd Child /Young person Forename

3rd Child /Young person Ethnicity

3rd Child /Young person Surname

3rd Child /Young person Religion

3rd Child /Young person Date of birth

3rd Child /Young person Language

4th Child /Young person

4th Child /Young person Local Authority ID Number

4th Child /Young person Gender/Identifies as (pronoun)

4th Child /Young person Forename

4th Child /Young person Ethnicity

4th Child /Young person Surname

4th Child /Young person Religion

4th Child /Young person Date of birth

4th Child /Young person Language

Parents/carers Details

Relationship

Gender/Identifies as (pronoun)

Name

Ethnicity

Contact number

Language

2nd Parent /Carer details

2nd Parent /Carer details Relationship

2nd Parent /Carer details Gender/Identifies as (pronoun)

2nd Parent /Carer details Name

2nd Parent /Carer details Ethnicity

2nd Parent /Carer details Contact number

2nd Parent /Carer details Language

Home Address Including Postcode

Full Address

If Looked After or residing at a temporary placement...

Temporary Full address including Postcode

Is this address confidential?

Foster/temporary Carer Details

Relationship

Contact Number

Name

Language

2nd Foster /Temporary Carer Details

2nd Foster /Temporary Carer Relationship

2nd Foster /Temporary Carer Contact Number

2nd Foster /Temporary Carer Name

2nd Foster /Temporary Carer Language

3rd Foster /Temporary Carer Details

3rd Foster /Temporary Carer Relationship

3rd Foster /Temporary Carer Contact Number

3rd Foster /Temporary Carer Name

3rd Foster /Temporary Carer Language

Communication

Any Special Communication Needs? If yes please provide details

Registered/Statutory Status. Please give details of name of child/young person, dates, category (if known)

Any child in the family currently on a Child in Need Plan?

Any child in family is or has been on a Child Protection Plan?

Any child or other family member is/has been looked after by a local authority?

Any child in the family has a disability?

Any current criminal proceedings?

Referral Details

Name of Referrer*

Role of Referrer*

Contact Number of Referrer*

Email Address of Referrer*

Name of Authorising Manager*

History of Case and Current Situation/Reason for Welfare Checks Being Required

Welfare Check Details. **Please note, our minimum charge is 1 hour

Days/dates visits are required

Time visits are required (if flexible please provide guideline – eg, anytime between 7am-6pm)

Length of visit required (usually one hour)**

Announced or Unannounced?

Are parents/carers aware that visits will be undertaken?

Frequency of visits (please specify, weekly, monthly, one off etc)

Service Requirement

Proposed start date

Proposed end/review date

Observations to be undertaken. Please give details.

Are there any persons who should not be present in the home?

Do you require the worker to check cupboards/refrigerators for food levels?

Are there specific things you would like the worker to look out for (eg, drug paraphernalia, weapons, safety hazards)?

If the check is to ensure certain persons/items should not be present, how thorough should the search be? In cupboards, outbuildings, loft?

Is it considered safe for a worker to attend alone or should 2:1 be considered?

Are there any other specific observations you would like the worker to make whilst carrying out the welfare check?

If the worker is unable to gain entry to the home (no answer when knocking etc) what action should be taken (eg, call parent, attempt a second visit, call EDT, attempt video call)

If any of the above are identified/observed during the welfare check, please advise what action should be taken, (eg, call the police, call EDT, ask persons not allowed to leave/check ID, remain outside until police arrive)

Please indicate the frequency that reports are required (after each visit, weekly etc) Please be mindful of the number of visits per week – For example, if visits are being undertaken 7days per week, one weekly report may not be a sufficient amount in order to provide a detailed account of each visit.

Risk Assessment - Child, please provide details e.g. whether this is current or historical. If YES, how would you like this to be managed by the worker?

Has the young person/child(ren) displayed any sexualised/challenging behaviour?

Has the young person/child(ren) shown aggression towards other children or to adults?

Are there any other risks that may be posed by the young person/child(ren) that the worker need to be aware of?

Risk Assessment – Adult/s, please provide details e.g. whether this is current or historical. If YES, how would you like this to be managed by the worker?

Does any adult residing in the home have issues of alcohol, solvent, or other substance misuse?

Has any adult residing in the home ever displayed sexualised behaviour towards children or adults?

Has any adult residing in the home ever displayed physical threats or violence towards a professional?

Has any adult residing in the home ever displayed verbal or racist abuse towards a professional?

Is any adult residing in the home engaging in, or have a history of, criminal activity?

Are there any other risks that may be posed by any adult residing in the home that the worker need to be aware of?

Please provide details of where invoices for this service should be sent (Please note, referral will not be accepted if this section is not completed)

Name of contact for invoicing*

Role of contact for invoicing*

Department of contact for invoicing*

Email address of contact for invoicing*

Telephone number of contact for invoicing*

Authorisation

Authorizing Manager*

Date authorised*