I have parental responsibility

Child's details
Child's name

First name

Last name
Date of birth or approximate age if not known
Gender
MaleFemale
Who does the child live with?
With youWith another person with parental responsibilityIn care (a looked after child)Not knownOther
If the child lives with another person with parental responsibility, please add their name and address below if known.
Child's address
Complete the address below only if it is different to yours. If you don't know the address then leave this blank.
Address Line 1
Address Line 2
Town
Postcode
Ethnicity
First language
Does the child have any known disabilities?
Are there any other children involved that you have parental responsibility for and need to be added (maximum of 4 additional children)? If you need to add more than 5 children, please put the information in the additional information area at the end of the form.
YesNo

Second child's details
Child's name

First name

Last name
Date of birth or approximate age if not known
Gender
MaleFemale
Who does the child live with?
With youWith another person with parental responsibilityIn care (a looked after child)Not knownOther
Does this child live at the same address as the first child? If they have a different address please add the details below if known.
YesNoNot known
Address Line 1
Address Line 2
Town
Postcode
Ethnicity
First language
Are there any other children involved that need to be added?
YesNo

Third child's details
Child's name

First name

Last name
Date of birth or approximate age if not known
Gender
MaleFemale
Who does the child live with?
With youWith another person with parental responsibilityIn care (a looked after child)Not knownOther
Does this child live at the same address as the first child? If they have a different address please add the details below if known.
YesNoNot known
Address Line 1
Address Line 2
Town
Postcode
Ethnicity
First language
Are there any other children involved that need to be added?
YesNo

Fourth child's details
Child's name

First name

Last name
Date of birth or approximate age if not known
Gender
MaleFemale
Who does the child live with?
With youWith another person with parental responsibilityIn care (a looked after child)Not knownOther
Does this child live at the same address as the first child? If they have a different address please add the details below if known.
YesNoNot known
Address Line 1
Address Line 2
Town
Postcode
Ethnicity
First language
Are there any other children involved that need to be added?
YesNo

Fifth child's details
Child's name

First name

Last name
Date of birth or approximate age if not known
Gender
MaleFemale
Who does the child live with?
With youWith another person with parental responsibilityIn care (a looked after child)Not knownOther
Does this child live at the same address as the first child? If they have a different address please add the details below if known.
YesNoNot known
Address Line 1
Address Line 2
Town
Postcode
Ethnicity
First language

Concerns

If the child is at immediate risk, for example they are home alone now or exposed to drugs now, please call the police immediately and do not continue with this form.
How would you categorise the risk?
PhysicalEmotionalSexualNeglectHome aloneMissingDomestic violencePerson posing risk to childExposure to drugsExposure to alcoholMental healthOther

Select all applicable options
If you selected 'Other' please give the details here.
How long is it since you first had these concerns?
When did you last see the child(ren)?
Have you reported your concerns before?
YesNo
If so, who did you report this to?
What advice were you given?
Were you given a reference number? If so please enter it here.
Are you aware of any substance misuse, domestic violence or adult mental health difficulties that affect the family? If so, please enter the details here.
Please tell us anything else you know about the family that may be relevant to the child(ren)'s safety and welfare?
Please explain what has happened, or what you are concerned about?

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