<p>Revised March 2015 P L AC E M E N T P AN E L T E M P L AT E</p><p>Placement Panel Date: Last Placement Panel Review Date: Form Completed by: Team manager / Social Worker / Personal Include role Advisor / IRO name.</p><p>Name of Child/Young Person: CareFirst ID: Ethnicity: Date of Birth / Age: Disability: Religion: Number of Placements (including this Placement Start Date: one) Placement Address: (Include reason if placed outside 20 mile radius) Placement type (fostering / residential) Date last assessment completed: Assessment Type: Which professionals and family members are currently offering support and what does this involve? Entry to Care: - Edge of Care Legal Status: - LPM - Emergency Protection Date of last LAC review & Outcome What is the long term plan for the child?</p><p>How are the child’s identity needs being met? Include issues relating to ethnicity, gender, disability and sexuality. Health: Issues / recommendations Date of last Medical: identified at the Initial / Review Health Assessment?</p><p>Placement Panel Form - Revised March 2015 Page 1 of 3 Revised March 2015 Is the child in receipt of children’s Yes No Comments continuing health care funding (CHC) If ‘No’ – Has a referral to children’s Note: referrals must be Not continuing health care been made? Yes No Date of referral: made ahead of the panel Applicable If ‘Yes’ – Please provide details of the progress made, in the placement, in relation to the young person’s continuing health care needs Has a referral to CAMHS been made? Yes No Date of referral: Has a CAMHS consultation taken Date of Yes No place: Consultation Detail of CAMHS involvement </p><p>Current School Educational Issues: SEN / SEBD / disability / School attendance / Impact of interruption to education If recommending placement move will Yes No Details this require a change in school? Details of Pathway Plan</p><p>Details of PEP Date of last PEP meeting Plus any information relating to education provision / employment etc Child / young person’s views of the placement / plan:</p><p>Guardian’s Views:</p><p>Family's Views:</p><p>IRO/Court's Views:</p><p>Placement Panel Form - Revised March 2015 Page 2 of 3 Revised March 2015 Historical Information: Include:  family information  entry to care  historic safeguarding concerns </p><p>Current Situation Include:  what is working well  any concerns or worries  placement update </p><p>Recommendations to Panel: Include reasons for recommendations </p><p>Reasons for child needing to remain in care:</p><p>Plans for Independence / Permanence: </p><p>Current cost of placement: £ per week Children’s continuing care (health) funding £ per week Current cost of educational provision: £ per week Cost attached to any recommendations:: £ per week </p><p>Social Work Signature Date Team manager Signature Date Team Manager Comments if required: </p><p>Placement Panel Form - Revised March 2015 Page 3 of 3</p>