Postcode Telephone Ethnicity/religion/first language Contact arrangements Father: Name Address Postcode Telephone Ethnicity/religion/first language Contact arrangements Siblings contact arrangements Any previous birth family name/address? Name of GP Name and Address Postcode Telephone Current carers Name Length of time provided care Address Postcode Telephone Any relationship to the person? Languages spoken GP of carers (if different from above) Name Address Postcode Telephone Agency details Name of Name of social agency worker Address Postcode Telephone Consent by birth parent/social worker* where young person does not have capacity to consent Consent already given in Looked After documents? if no then complete below Yes / No, I agree to being assessed Date Signature Name Relationship * Authorised by LA to give consent on their behalf Part A completed by: Telephone Date Part B To be completed by the examining health professional and retained within the person’s health record. Consent by the young person with capacity to consent is essential. Does the young person have capacity to consent? Yes/No
Postcode Telephone Ethnicity/religion/first language Contact arrangements Father: Name Address Postcode Telephone Ethnicity/religion/first language Contact arrangements Siblings contact arrangements Any previous birth family name/address? Name of GP Name and Address Postcode Telephone Current carers Name Length of time provided care Address Postcode Telephone Any relationship to the person? Languages spoken GP of carers (if different from above) Name Address Postcode Telephone Agency details Name of agency Name of social worker Address Postcode Telephone Consent by birth parent/social worker* where young person does not have capacity to consent Consent already given in Looked After documents? Yes / No, if no then complete below I agree to being assessed Date Signature Name Relationship * Authorised by LA to give consent on their behalf Part A completed by: Telephone Date Part B To be completed by the examining health professional and retained within the person’s health record. Consent by the young person with capacity to consent is essential. Does the young person have capacity to consent? Yes/No