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1
Ethnicity
WhiteBritish WhiteIrish
AnyotherWhitebackground
TravellerofIrishHeritage Gypsy/Roma
White/BlackCaribbean White/BlackAfrican
White/Asian
Anyothermixedbackground
Indian Pakistani
Bangladeshi
AnyotherAsianbackground
Caribbean African
AnyotherBlackbackground
Chinese Anyotherethnicgroup
Prefernottosay Informationnotyetobtained
Gender
Male Female Unborn
Is an interpreter required? Language
Yes No
Child(ren)/Young Person(s)’s details
Contact Details (Telephonenumber,mobile,email)
UPN
School/College/Nursery
Last Name First Name Also known as
Age DOB/EDD(--/--/-----) Address Postcode
CROYDON EARLY HELP ASSESSMENT FORM
Category of agency
Education(4yearsandover) SocialCare Health MentalHealth Earlyyears
Housing FamilySupport Police/Probation VoluntaryOrganisation
Assessor’s Details
Name of Assessor
Job role
Organisation
Address
Telephone number
Postcode
Disability/SEN Isdisabled Isondisabilityregister AnySENneeds Pleasespecify
Date assessment started
2
Ethnicity
WhiteBritish WhiteIrish
AnyotherWhitebackground
TravellerofIrishHeritage Gypsy/Roma
White/BlackCaribbean White/BlackAfrican
White/Asian
Anyothermixedbackground
Indian Pakistani
Bangladeshi
AnyotherAsianbackground
Caribbean African
AnyotherBlackbackground
Chinese Anyotherethnicgroup
Prefernottosay Informationnotyetobtained
Ethnicity
WhiteBritish WhiteIrish
AnyotherWhitebackground
TravellerofIrishHeritage Gypsy/Roma
White/BlackCaribbean White/BlackAfrican
White/Asian
Anyothermixedbackground
Indian Pakistani
Bangladeshi
AnyotherAsianbackground
Caribbean African
AnyotherBlackbackground
Chinese Anyotherethnicgroup
Prefernottosay Informationnotyetobtained
Gender
Male Female Unborn
Gender
Male Female Unborn
Child(ren)/Young Person(s)’s details
Child(ren)/Young Person(s)’s details
Contact Details (Telephonenumber,mobile,email)
UPN
School/College/Nursery
Contact Details (Telephonenumber,mobile,email)
UPN
School/College/Nursery
Last Name First Name Also known as
Last Name First Name Also known as
Age DOB/EDD(--/--/-----) Address Postcode
Age DOB/EDD(--/--/-----) Address Postcode
Disability/SEN Isdisabled Isondisabilityregister AnySENneeds Pleasespecify
Disability/SEN Isdisabled Isondisabilityregister AnySENneeds Pleasespecify
Is an interpreter required? Language
Yes No
Is an interpreter required? Language
Yes No
3
Ethnicity
WhiteBritish WhiteIrish
AnyotherWhitebackground
TravellerofIrishHeritage Gypsy/Roma
White/BlackCaribbean White/BlackAfrican
White/Asian
Anyothermixedbackground
Indian Pakistani
Bangladeshi
AnyotherAsianbackground
Caribbean African
AnyotherBlackbackground
Chinese Anyotherethnicgroup
Prefernottosay Informationnotyetobtained
Ethnicity
WhiteBritish WhiteIrish
AnyotherWhitebackground
TravellerofIrishHeritage Gypsy/Roma
White/BlackCaribbean White/BlackAfrican
White/Asian
Anyothermixedbackground
Indian Pakistani
Bangladeshi
AnyotherAsianbackground
Caribbean African
AnyotherBlackbackground
Chinese Anyotherethnicgroup
Prefernottosay Informationnotyetobtained
Gender
Male Female Unborn
Gender
Male Female Unborn
Child(ren)/Young Person(s)’s details
Child(ren)/Young Person(s)’s details
Contact Details (Telephonenumber,mobile,email)
UPN
School/College/Nursery
Contact Details (Telephonenumber,mobile,email)
UPN
School/College/Nursery
Last Name First Name Also known as
Last Name First Name Also known as
Age DOB/EDD(--/--/-----) Address Postcode
Age DOB/EDD(--/--/-----) Address Postcode
Disability/SEN Isdisabled Isondisabilityregister AnySENneeds Pleasespecify
Disability/SEN Isdisabled Isondisabilityregister AnySENneeds Pleasespecify
Is an interpreter required? Language
Yes No
Is an interpreter required? Language
Yes No
4
Ethnicity
WhiteBritish WhiteIrish
AnyotherWhitebackground
TravellerofIrishHeritage Gypsy/Roma
White/BlackCaribbean White/BlackAfrican
White/Asian
Anyothermixedbackground
Indian Pakistani
Bangladeshi
AnyotherAsianbackground
Caribbean African
AnyotherBlackbackground
Chinese Anyotherethnicgroup
Prefernottosay Informationnotyetobtained
Ethnicity
WhiteBritish WhiteIrish
AnyotherWhitebackground
TravellerofIrishHeritage Gypsy/Roma
White/BlackCaribbean White/BlackAfrican
White/Asian
Anyothermixedbackground
Indian Pakistani
Bangladeshi
AnyotherAsianbackground
Caribbean African
AnyotherBlackbackground
Chinese Anyotherethnicgroup
Prefernottosay Informationnotyetobtained
Gender
Male Female Unborn
Gender
Male Female Unborn
Child(ren)/Young Person(s)’s details
Child(ren)/Young Person(s)’s details
Contact Details (Telephonenumber,mobile,email)
UPN
School/College/Nursery
Contact Details (Telephonenumber,mobile,email)
UPN
School/College/Nursery
Last Name First Name Also known as
Last Name First Name Also known as
Age DOB/EDD(--/--/-----) Address Postcode
Age DOB/EDD(--/--/-----) Address Postcode
Disability/SEN Isdisabled Isondisabilityregister AnySENneeds Pleasespecify
Disability/SEN Isdisabled Isondisabilityregister AnySENneeds Pleasespecify
Is an interpreter required? Language
Yes No
Is an interpreter required? Language
Yes No
5
Type of responsibility
Maincarer Nextofkin
Emergencycontact Parentalresponsibility
Type of responsibility
Maincarer Nextofkin
Emergencycontact Parentalresponsibility
Ethnicity
WhiteBritish WhiteIrish
AnyotherWhitebackground
TravellerofIrishHeritage Gypsy/Roma
White/BlackCaribbean White/BlackAfrican
White/Asian
Anyothermixedbackground
Indian Pakistani
Bangladeshi
AnyotherAsianbackground
Caribbean African
AnyotherBlackbackground
Chinese Anyotherethnicgroup
Prefernottosay Informationnotyetobtained
Ethnicity
WhiteBritish WhiteIrish
AnyotherWhitebackground
TravellerofIrishHeritage Gypsy/Roma
White/BlackCaribbean White/BlackAfrican
White/Asian
Anyothermixedbackground
Indian Pakistani
Bangladeshi
AnyotherAsianbackground
Caribbean African
AnyotherBlackbackground
Chinese Anyotherethnicgroup
Prefernottosay Informationnotyetobtained
Gender
Male Female
Gender
Male Female
Parent / Carer details
Parent / Carer details
Contact Details (Telephonenumber,mobile,email)
Contact Details (Telephonenumber,mobile,email)
Last Name First Name Also known as
Last Name First Name Also known as
Age DOB(--/--/-----) Address Postcode
Age DOB(--/--/-----) Address Postcode
Disability/SEN Isdisabled Isondisabilityregister AnySENneeds Pleasespecify
Disability/SEN Isdisabled Isondisabilityregister AnySENneeds Pleasespecify
Is an interpreter required? Language
Yes No
Is an interpreter required? Language
Yes No
6
Relationship to child(ren)/Young person
Relationship to child(ren)/Young person
Ethnicity
WhiteBritish WhiteIrish
AnyotherWhitebackground
TravellerofIrishHeritage Gypsy/Roma
White/BlackCaribbean White/BlackAfrican
White/Asian
Anyothermixedbackground
Indian Pakistani
Bangladeshi
AnyotherAsianbackground
Caribbean African
AnyotherBlackbackground
Chinese Anyotherethnicgroup
Prefernottosay Informationnotyetobtained
Ethnicity
WhiteBritish WhiteIrish
AnyotherWhitebackground
TravellerofIrishHeritage Gypsy/Roma
White/BlackCaribbean White/BlackAfrican
White/Asian
Anyothermixedbackground
Indian Pakistani
Bangladeshi
AnyotherAsianbackground
Caribbean African
AnyotherBlackbackground
Chinese Anyotherethnicgroup
Prefernottosay Informationnotyetobtained
Gender
Male Female
Gender
Male Female
Is an interpreter required? Language
Yes No
Is an interpreter required? Language
Yes No
Other significant people
Other significant people
Contact Details (Telephonenumber,mobile,email)
Contact Details (Telephonenumber,mobile,email)
Last Name First Name Also known as
Last Name First Name Also known as
Age DOB(--/--/-----) Address Postcode
Age DOB(--/--/-----) Address Postcode
Disability/SEN Isdisabled Isondisabilityregister AnySENneeds Pleasespecify
Disability/SEN Isdisabled Isondisabilityregister AnySENneeds Pleasespecify
7
Relationship to child(ren)/Young person
Relationship to child(ren)/Young person
Ethnicity
WhiteBritish WhiteIrish
AnyotherWhitebackground
TravellerofIrishHeritage Gypsy/Roma
White/BlackCaribbean White/BlackAfrican
White/Asian
Anyothermixedbackground
Indian Pakistani
Bangladeshi
AnyotherAsianbackground
Caribbean African
AnyotherBlackbackground
Chinese Anyotherethnicgroup
Prefernottosay Informationnotyetobtained
Ethnicity
WhiteBritish WhiteIrish
AnyotherWhitebackground
TravellerofIrishHeritage Gypsy/Roma
White/BlackCaribbean White/BlackAfrican
White/Asian
Anyothermixedbackground
Indian Pakistani
Bangladeshi
AnyotherAsianbackground
Caribbean African
AnyotherBlackbackground
Chinese Anyotherethnicgroup
Prefernottosay Informationnotyetobtained
Gender
Male Female
Gender
Male Female
Is an interpreter required? Language
Yes No
Is an interpreter required? Language
Yes No
Other significant people
Other significant people
Contact Details (Telephonenumber,mobile,email)
Contact Details (Telephonenumber,mobile,email)
Last Name First Name Also known as
Last Name First Name Also known as
Age DOB(--/--/-----) Address Postcode
Age DOB(--/--/-----) Address Postcode
Disability/SEN Isdisabled Isondisabilityregister AnySENneeds Pleasespecify
Disability/SEN Isdisabled Isondisabilityregister AnySENneeds Pleasespecify
8
Professionals / Key Agencies involved
Last Name
Organisation
First Name
Names of family members currently receiving support
Involvement start date
Job Role
Telephone number
Professionals / Key Agencies involved
Last Name
Organisation
First Name
Names of family members currently receiving support
Involvement start date
Job Role
Telephone number
Professionals / Key Agencies involved
Last Name
Organisation
First Name
Names of family members currently receiving support
Involvement start date
Job Role
Telephone number
9
Professionals / Key Agencies involved
Last Name
Organisation
First Name
Names of family members currently receiving support
Involvement start date
Job Role
Telephone number
Professionals / Key Agencies involved
Last Name
Organisation
First Name
Names of family members currently receiving support
Involvement start date
Job Role
Telephone number
Professionals / Key Agencies involved
Last Name
Organisation
First Name
Names of family members currently receiving support
Involvement start date
Job Role
Telephone number
Primary reason for assessment
Health Emotional,Social&Behavioural Identity,Independence,Relationships&SocialPresentation
Learning&Participation Parents&Carers Family&Environment Housing,Employment&Finance
10
What has led to this assessment?
11
Parent / Carer’s comments
Child / Young Person’s comments
Health – general health; physical development
How well on a scale of 1-6 is the family doing in this area? *Required(1–notwell;6–verywell) 1 2 3 4 5 6
Development of the unborn baby, infant, child or young person
12
Parent / Carer’s comments
Child / Young Person’s comments
Emotional, Social & Behavioural – emotional and social development; behavioural development
How well on a scale of 1-6 is the family doing in this area? *Required(1–notwell;6–verywell) 1 2 3 4 5 6
13
Parent / Carer’s comments
Child / Young Person’s comments
Identity, Independence, Relationships & Social Presentation - Identity, self-esteem, self-image and social presentation, family and social relationships, self-care and independence
How well on a scale of 1-6 is the family doing in this area? *Required(1–notwell;6–verywell) 1 2 3 4 5 6
14
Parent / Carer’s comments
Child / Young Person’s comments
Learning & Participation – understanding, reasoning and problem solving, participation in learning, education, and employment, progress and achievement, aspirations, speech, language and communication
How well on a scale of 1-6 is the family doing in this area? *Required(1–notwell;6–verywell) 1 2 3 4 5 6
15
Parent / Carer’s comments
Child / Young Person’s comments
Basic care, ensuring safety and protection; emotional warmth and stability; guidance, boundaries and stimulation
How well on a scale of 1-6 is the family doing in this area? *Required(1–notwell;6–verywell) 1 2 3 4 5 6
Parents & Carers
16
Parent / Carer’s comments
Child / Young Person’s comments
Family & Environment – family history, functioning and wellbeing, wider family, social and community elements
How well on a scale of 1-6 is the family doing in this area? *Required(1–notwell;6–verywell) 1 2 3 4 5 6
Family, Environment & Finance
17
Parent / Carer’s comments
Child / Young Person’s comments
Housing, Employment & Finance – housing, employment and financial considerations
How well on a scale of 1-6 is the family doing in this area? *Required(1–notwell;6–verywell) 1 2 3 4 5 6
18
What needs to change? How will we know when it has been achieved?
What needs to change?
19
Consent Details
Please submit securely to [email protected]
Please provide feedback about the use of this form via the survey monkey link www.surveymonkey.com/s/zb2bxyq
Guidance for this form is available at www.practitionerspacecroydon.co.uk/support-assessment/is-it-for-me-caf
Consent Statement & Approach
Consent statement for information storage and information sharing
We need to collect the information in this EHA form so that we can understand what help you may need. If we cannot cover all of your needs we may need to share some of this information with the other organisations, so that they can help us to provide the services you need.
We will treat your information as confidential and we will not share it with any other organisation unless we are required by law to share it or unless you or any other person will come to some harm if we do not share it. In any case we will only ever share the minimum information we need to share.
Anonymised data from your record may also be used to help us monitor and improve services in the future.
I understand the information that is recorded on this form and that it will be stored and used for the purpose of providing services to:
Me This infant, child or young person for whom I am a parent This infant, child or young person for whom I am a carer
I have had the reasons for information sharing and information storage explained to me and I understand those reasons:
Yes No
I agree to the sharing of information, as agreed, between the services areas listed below. Please tick all the areas you are happy to share information with.
Education Social Care Health Mental Health Housing
Family Support Police/Probation Voluntary Organisation
The parent(s) / carer(s) give their consent
Yes No Parent / Carer Signature Date
The young person gives their consent
Yes No Young Person Signature Date
150355
Date assessment completed