Family & Household We want families in Staffordshire to be safe, healthy, self-reliant, educated, responsible and informed. This requires families to be supported in the development of the skills and resources to cope with current and future challenges whilst ensuring they can access the correct help at the right time and in the right place. Please use the space below to give details of the child’s parents/carers. Name Date of Parental Full Address (if different to Telephone Ethnicity plus Birth Responsibility No. Religion (Y/N) Please use the below to give details of other people who live with the child, are related to or play a significant role in their life including siblings, half siblings and other family members. Name Who has Reside Relationship to Age DOB Ethnicity (if they Parental with the plus are a sibling and of school Responsibility? child? age, please state which school Religion Yes or No attended) What is the family’s first language? Additional Relevant Information Is the family part of the Building Resilient Families and Communities programme? YES/NO Have any Early Help Assessments been initiated for any other members of the family? YES/NO (If so, who and when?) Has there been any previous support for the child/young person that is relevant in this YES/NO authority, or in a previous authority? If so, please provide further information. Are any agencies involved in supporting other members of the family / household? If so, please provide further information. 3
Family & Household We want families in Staffordshire to be safe, healthy, self-reliant, educated, responsible and informed. This requires families to be supported in the development of the skills and resources to cope with current and future challenges whilst ensuring they can access the correct help at the right time and in the right place. Please use the space below to give details of the child’s parents/carers. Name Date of Birth Parental Responsibility (Y/N) Full Address (if different to Telephone No. Ethnicity plus Religion Please use the below to give details of other people who live with the child, are related to or play a significant role in their life including siblings, half siblings and other family members. Name Who has Parental Responsibility? Reside with the child? Yes or No Relationship to (if they are a sibling and of school age, please state which school attended) Age DOB Ethnicity plus Religion What is the family’s first language? Additional Relevant Information Is the family part of the Building Resilient Families and Communities programme? YES/NO Have any Early Help Assessments been initiated for any other members of the family? (If so, who and when?) YES/NO Has there been any previous support for the child/young person that is relevant in this authority, or in a previous authority? If so, please provide further information. YES/NO Are any agencies involved in supporting other members of the family / household? If so, please provide further information. 3