Parental Assessment Tool
Medway RIVER Treatment & Recovery Service
Document Title
Email Address Sender FT
Date assessment completed
*
/
Day
/
Month
Year
Date
Completed by keyworker
*
First Name
Last Name
Keyworker email address
*
firstname.surname@forwardtrust.org.uk
Back
Next
Save
CLIENT INFORMATION
Illy Reference
*
Client name
*
First Name
Last Name
Back
Next
Save
CHILDREN INFORMATION
Is the client pregnant
*
Please Select
Yes
No
If pregnant, expected date of delivery
/
Day
/
Month
Year
How many children live with the client (U18)
*
No children (U18) living with client
Client declined to answer
Undisclosed number
Please specify number...
Parental responsibility for children under 18
*
Please Select
Yes
No
Client declined to answer
Parental status
*
Please Select
All children (U18) live with client
Some children (U18) live with client
None (U18) live with client
Client declined to answer
Child 1
What help are the client's children/children living with the client receiving?
Early Help
Child In Need
Has a Child Protection Plan
Looked After Child
None of the children are receiving any help
Client declined to answer
Child 2
What help are the client's children/children living with the client receiving?
Early Help
Child In Need
Has a Child Protection Plan
Looked After Child
None of the children are receiving any help
Client declined to answer
Child 3
What help are the client's children/children living with the client receiving?
Early Help
Child In Need
Has a Child Protection Plan
Looked After Child
None of the children are receiving any help
Client declined to answer
Back
Next
Save
PARENTAL ASSESSMENT
Do you live with other people?
*
Please Select
Yes
No
Who do you live with?
*
Please Select
Partner
Partner & Children
Parents
Other Family
Friends
Other
Do you have children?
*
Please Select
Yes
No
How often do you see them?
*
Please Select
Daily
Weekly
Monthly
Less Than Monthly
Not At All
Do you have contact with any other children?
*
Please Select
Yes
No
Please detail...
*
Are social services involved?
*
Please Select
Yes
No
Back
Next
Save
CHILD DETAILS
Child A
Name
First Name
Last Name
Date of birth
/
Day
/
Month
Year
Does the child live at the clients address?
Please Select
Yes
No
Address
Street Address
Street Address Line 2
Town
County
Post Code
Gender
Please Select
Male
Female
Not Specified
Not Known
Relationship
GP Surgery
School / Nursery
Child B
Name
First Name
Last Name
Date of birth
/
Day
/
Month
Year
Does the child live at the clients address?
Please Select
Yes
No
Address
Street Address
Street Address Line 2
Town
County
Post Code
Gender
Please Select
Male
Female
Not Specified
Not Known
Relationship
GP Surgery
School / Nursery
Child C
Name
First Name
Last Name
Date of birth
/
Day
/
Month
Year
Does the child live at the clients address?
Please Select
Yes
No
Address
Street Address
Street Address Line 2
Town
County
Post Code
Gender
Please Select
Male
Female
Not Specified
Not Known
Relationship
GP Surgery
School / Nursery
Child D
Name
First Name
Last Name
Date of birth
/
Day
/
Month
Year
Does the child live at the clients address?
Please Select
Yes
No
Address
Street Address
Street Address Line 2
Town
County
Post Code
Gender
Please Select
Male
Female
Not Specified
Not Known
Relationship
GP Surgery
School / Nursery
Child E
Name
First Name
Last Name
Date of birth
/
Day
/
Month
Year
Does the child live at the clients address?
Please Select
Yes
No
Address
Street Address
Street Address Line 2
Town
County
Post Code
Gender
Please Select
Male
Female
Not Specified
Not Known
Relationship
GP Surgery
School / Nursery
Back
Next
Save
PROFESSIONALS WORKING WITH CHILDREN
Child A
Child protection plan
Please Select
Yes
No
Details
Child in need plan
Please Select
Yes
No
Details
Looked after by local authority
Please Select
Yes
No
Details
Family intensive support process
Please Select
Yes - In Progress
No
Details
TAC in place?
Please Select
Yes
No
Details
Substance misuse related?
Please Select
Yes
No
Details
Child B
Child protection plan
Please Select
Yes
No
Details
Child in need plan
Please Select
Yes
No
Details
Looked after by local authority
Please Select
Yes
No
Details
Family intensive support process
Please Select
Yes - In Progress
No
Details
TAC in place?
Please Select
Yes
No
Details
Substance misuse related?
Please Select
Yes
No
Details
Child C
Child protection plan
Please Select
Yes
No
Details
Child in need plan
Please Select
Yes
No
Details
Looked after by local authority
Please Select
Yes
No
Details
Family intensive support process
Please Select
Yes - In Progress
No
Details
TAC in place?
Please Select
Yes
No
Details
Substance misuse related?
Please Select
Yes
No
Details
Child D
Child protection plan
Please Select
Yes
No
Details
Child in need plan
Please Select
Yes
No
Details
Looked after by local authority
Please Select
Yes
No
Details
Family intensive support process
Please Select
Yes - In Progress
No
Details
TAC in place?
Please Select
Yes
No
Details
Substance misuse related?
Please Select
Yes
No
Details
Child E
Child protection plan
Please Select
Yes
No
Details
Child in need plan
Please Select
Yes
No
Details
Looked after by local authority
Please Select
Yes
No
Details
Family intensive support process
Please Select
Yes - In Progress
No
Details
TAC in place?
Please Select
Yes
No
Details
Substance misuse related?
Please Select
Yes
No
Details
Back
Next
Save
PARENTAL ASSESSMENT
Where do you keep drugs / alcohol?
*
Could your children have access to them?
*
Please Select
Yes
No
Does anyone in your household use needles?
*
Please Select
Yes
No
Where do you keep them (used and new)?
*
How do you dispose of them?
*
Where do you keep other paraphernalia?
*
How do you dispose of paraphernalia?
*
Are there any other adults in your household?
*
Please Select
Yes
No
Do they use any substances?
*
Please Select
Yes
No
Client declined to answer
Known substances used by other in household.
Who comes in and out of your home?
*
What other significant adults do your child/children have in their lives?
*
Where are your children when you use drugs / alcohol?
*
How do you make decisions about what you spend your money on?
*
Would you say your children were aware of your substance misuse?
*
Please Select
Yes
No
How would you say your substance misuse affects your parenting ability?
*
Does your substance misuse affects plans you make with your children?
*
Please Select
Yes
No
Do your children attend school / nursery regularly?
*
Please Select
Yes
No
Back
Next
Save
ADDITIONAL RECOVERY WORKER NOTES
Back
Next
Save
Assessment Completed
Save
Submit
Should be Empty: