THE CARE PLANNING, PLACEMENT AND CASE REVIEW (WALES) REGULATIONS 2015 HEALTH CARE NEEDS NOTIFICATION FORM LOOKED AFTER CHILD / YOUNG PERSON’S DETAILS Name of Child/Young Person: (also known as) Date of Birth: Gender: Male Female NHS Number: Carer’s Name: Placement Address: Post Code: Telephone Number: Is this Placement: Foster Carer Placement with parents Connected Foster Carer Residential School: Children’s Home Pre-Adoption Placement Parent & Baby Placement Secure Children’s Home Other: Young Offenders Institution Date of commencement of Placement: Was this an emergency Placement? Yes No Yes No Not Known Is the placement address to be withheld from the parent(s)? CONTACT DETAILS OF KEY STAFF FROM PLACING HEALTH BOARD/AUTHORITY Health Board/Trust of Origin (Commissioning) LAC Nurse/LAC Team of Origin: Social Worker Name: Tel No: Local Authority Children’s Services of Origin: Address: Local Authority Education Department of Origin: REASON FOR THE PLACEMENT Becomes Looked After Change of Placement Pre-Adoption placement Other – please specify
THE CARE PLANNING, PLACEMENT AND CASE REVIEW (WALES) REGULATIONS 2015 HEALTH CARE NEEDS NOTIFICATION FORM LOOKED AFTER CHILD / YOUNG PERSON’S DETAILS Name of Child/Young Person: (also known as) Date of Birth: Gender: Male Female NHS Number: Carer’s Name: Placement Address: Post Code: Telephone Number: Is this Placement: Foster Carer Connected Foster Carer Children’s Home Parent & Baby Placement Other: Placement with parents Residential School: Pre-Adoption Placement Secure Children’s Home Young Offenders Institution Date of commencement of Placement: Was this an emergency Placement? Yes No Is the placement address to be withheld from the parent(s)? Yes No Not Known CONTACT DETAILS OF KEY STAFF FROM PLACING HEALTH BOARD/AUTHORITY Health Board/Trust of Origin (Commissioning) LAC Nurse/LAC Team of Origin: Local Authority Children’s Services of Origin: Social Worker Name: Tel No: Address: Local Authority Education Department of Origin: REASON FOR THE PLACEMENT Becomes Looked After Pre-Adoption placement Change of Placement Other – please specify
Health%20Care%20Needs%20Notification%20Form%20updated%20041016.docx