Part 1 – Details of Proposed Respite Arrangements

Names, Address and D of B of proposed respite carers:

Telephone number:.................................................................

Name of current Foster Carers:............................................

Relationship to proposed respite carers:..............................

Name and D of B of Children requiring respite:

Proposed period of respite: From .......................To.............................

Is the proposed plan for the children to move to the respite carers’ home or for the carers to move into the current foster carers’ home? Yes No

Details of household members:

Part 2 - Checks

1) Enhanced DBS checks for all adults over 18 in the home:

2) CPR checks for all adults over 18 in the home:

3) Medical check for each prospective respite carer. Consent given to call GP to ascertain if there would be any contraindication to foster:

Date: ......................................................................................

Name of GP called and date: ...............................................

Comments: ...........................................................................

4) Referee

Name, address and phone number of referee:
.................................................................................................
.................................................................................................
.................................................................................................

Relationship to proposed respite carers and length of time known:
.................................................................................................
.................................................................................................

Date of phone call: .................................................................

Comments: .............................................................................
.................................................................................................
.................................................................................................

5a) Is the proposed respite is to take place in the carers’ home?

Date home visited ...................................................................

5b) Has a Health and Safety check been completed?
Yes?No

Comments: .............................................................................
.................................................................................................
.................................................................................................

5c) What are the proposed sleeping arrangements for the children?

Part 3

1) What is the proposed carers’ relationship with the children they are proposing to look after? Give details of the length of time they have known the children and details of their relationship.

2) What preparation work has been done with the proposed carers? Please comment on their understanding of the fostering task.

3) Have the child/ren’s social worker/practice manager been notified?

Yes/No Date....................................

What are their views/comments?...........................................
.................................................................................................
.................................................................................................

4) What is the support plan for the placement for the proposed respite period? Please cover monitoring, emergency and support issues.

5) What are the potential strengths and risks associated with this respite  arrangement?

Have you discussed this arrangement with your PM?
Yes/ No

Comments: .............................................................................
.................................................................................................
.................................................................................................

7) What information has been given to the foster carers about fostering? e.g Baby care info sheet, handbook

8) Has information been given to the carers about emergency situations?
e.g. On call rota, contact numbers
Please list:

9) What are the financial arrangements?

Part 4 - Details of the children

It is essential that the proposed respite carers are given written information about the child/ren who it is being proposed they look after.

The questions/information below could be completed by the supervising social worker and given directly to the carer in the absence of any other existing appropriate document.

This is the minimum level of information. If this form is not used please detail what other documentation/information has been given to the carer?

1) What is child/rens’ legal status?
.................................................................................................

2) Details of birth family:
Name of parents or significant others
.................................................................................................
.................................................................................................

 3) Contact arrangements during the respite period:
.................................................................................................
.................................................................................................

4) How will they be managed?
.................................................................................................
.................................................................................................

5) Have the child/ren’s parents been notified of the respite arrangements?

Date .................By whom ......................................................

Their view or any comments:
.................................................................................................
.................................................................................................
.................................................................................................

6) GP/ Health visitor details
.................................................................................................
.................................................................................................

7) Do the child/ren take any medication?
.................................................................................................
.................................................................................................

8) Do the child/ren have any allergies?
.................................................................................................
.................................................................................................

9) Brief description of the child/ren
(any special needs, developmental delay, emotional behavioural difficulties, hobbies, interests):

Part 5

Date passed to Team Manager
Any comments?
.................................................................................................
.................................................................................................
.................................................................................................

Date passed to Service Manager
Any comments?
.................................................................................................
.................................................................................................
.................................................................................................

I agree to the proposed respite provision

Signed .......................................................................Service Manager

Date..........................................................................................