Specialist To be completed in the of a Child Protection Case Conference: Name and Age of Person(s) perceived to be responsible for Alleged Abuse or source of potential risk to child, if known. (If more than one, indicate which (if any) is primary). If age is unknown, give estimate: Name: Age Tick to indicate if primary (if unknown, alleged abuser: give estimate): Relationship of person perceived to be Primary Alleged Abuser or source of potential risk to Each Child (use code list): Second Third Fourth Fifth Sixth Child Child Child Child Child Child Codes: 01 - Birth Mother 08 - Grandfather 15 - Relationship (Male) please specify 02 - Birth Father 09 - Aunt 16 Other Relationship (Female) please specify 03 - Step-mother 10 - Uncle 17 - Relationship Not (Male) 04 - Step-father 11 - Sister 18 - Relationship Not (Female) 05 - Female Co-Habitee 12 - Brother 19 - Adoptive Mother - Male Co-Habitee No Relation (Male) Adoptive Father 06 13 - 20 - 07 - Grandmother 14 - No Relation (Female) 21 - Other (please specify) Person perceived to be Alleged Abuser or source of potential risk moved? Yes No SIGNATURE PAGE
Specialist To be completed in the of a Child Protection Case Conference: Name and Age of Person(s) perceived to be responsible for Alleged Abuse or source of potential risk to child, if known. (If more than one, indicate which (if any) is primary). If age is unknown, give estimate: Name: Age (if unknown, give estimate): Tick to indicate if primary alleged abuser: Relationship of person perceived to be Primary Alleged Abuser or source of potential risk to Each Child (use code list): Child Second Child Third Child Fourth Child Fifth Child Sixth Child Codes: 01 - Birth Mother 08 - Grandfather 15 - Relationship (Male) please specify 02 - Birth Father 09 - Aunt 16 Other Relationship (Female) please specify 03 - Step-mother 10 - Uncle 17 - Relationship Not (Male) 04 - Step-father 11 - Sister 18 - Relationship Not (Female) 05 - Female Co-Habitee 12 - Brother 19 - Adoptive Mother 06 - Male Co-Habitee 13 - No Relation (Male) 20 - Adoptive Father 07 - Grandmother 14 - No Relation (Female) 21 - Other (please specify) Person perceived to be Alleged Abuser or source of potential risk moved? Yes No SIGNATURE PAGE
Childs-Plan-Dec-2017.docx