1 Family Violence Child Protection Intervention Procedures

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1 1 1.1 Guiding Principles Six Step Process Identification Support and Management Assess and Manage Risk Safety Planning /Intervention 4 Death of a Child and Sibling Assessment 7 Family Safety and Security process Documentation Reporting or Referral Staff Support and Safety Appendix 1: Child Abuse Management Flowchart Appendix 2: Definitions Appendix 3: Role of CFSRC (Child and Family Safety Review Committee), CPAC (Child Protection Advisory Committee), Child Youth and Family and the New Zealand Police Appendix 4: Four Recognised Categories of Child Abuse Appendix 5: Legal and Privacy Issues Appendix 6 What to do when a child tells of his or her abuse Appendix 7 Safety and Security Guidelines Appendix 8 CYF Notification Template Guiding Principles Canterbury District Health Board supports the kaupapa /philosophy of the National Protocol agreed by Crown Health Enterprises and New Zealand Children and Young Persons Services Guiding Principles that support effective Child Protection Interventions are: The welfare and interests of the child or young person shall be the first and paramount consideration (CYP & F Act 1989) Tamariki/children and rangatahi/young persons are our taonga/treasures. They have a right; to full emotional, spiritual and physical wellbeing to develop their own potential in an environment that is nurturing, protective and safe from abuse. Ref: 0928 Page 1 of 25

2 The whanau/family s primary role in providing the care, welfare and safety of children must be valued. Health services should contribute to the nurturing and protection of the child and advocate for them as part of their role to promote, protect and preserve the public health. Health services for the care and protection of children should be built on a bicultural partnership in accordance with the Treaty of Waitangi. All children and their whanau/families have the right to health services involved with care and protection that are accessible, culturally aware, appropriate and responsive. It is particularly important for children that services are provided in environments which are comfortable and appropriate to their needs and age. Effective child protection and child abuse care strategies require liaison with statutory agencies and the community. No one should work in isolation in child protection. Child protection work is recognised as complex and stressful. A consultative, multidisciplinary team approach must be used in order to provide both an effective and caring service and adequate support for workers. The child and their whanau/families have a right to a high quality service. This requires that staff have adequate specialised training and that services are evaluated and monitored to ensure they are maintained at an acceptable level. This procedure applies to the unborn child. Management of risk to the unborn child should occur in close consultation with maternity services and the Lead Maternity Carer. Early intervention where care and protection concerns are identified maximises the opportunity for best outcomes. A referral can be made to CYF during the antenatal period. 1.2 Six Step Process Identification In all situations where a member of staff has a concern about a child being or likely to be abused (Definition see Appendix 2) either by disclosure, or recognition of signs or symptoms by an adult or another child, they will ensure that the appropriate process is followed and referrals to key clinical staff (e.g. Clinical Coordinator Paediatrician, Psychiatrist, Social Worker, Charge Nurse, Clinical Manager, Case Manager) are actioned. Ref: 0928 Page 2 of 25

3 Report the concerns to your immediate Line Manager/Supervisor. All cases must be referred to the Child and Family Safety Service or the Mental Health Child Protection Coordinator Support and Management All child abuse concerns must be reported to key members of the patient s multi-disciplinary team and action should be taken to protect the child when appropriate. At any time when care and protection concerns exist a staff member/team or department may consult and seek support from the Child and Family Safety Service/Mental Health Child Protection Coordinator. Involve an appropriate staff member of the same ethnicity as the child in the decision making and consultation whenever possible. Where the child is Maori, a Maori health professional (Maori Health Worker) must be involved in this consultation whenever possible. CDHB interpreters should always be used where there appears to be language issues. As a general rule, family members should not be used as interpreters. Offer appropriate cultural support where possible, e.g. Pacific Trust Canterbury, Pacific Island Evaluation, Christchurch Resettlement Services Assess and Manage Risk Refer to Appendix 4 Four Recognised Categories of Child Abuse. Identify all apparent risk factors and alleged /suspected abuse that pertain to the child so that appropriate information can be presented to the manager/supervisor and key clinical staff (Paediatrician, Psychiatrist, Social Worker, Case Manager, Charge Nurse, Clinical Manager, Child and Family Safety Service/Mental Health Child Protection Coordinator, etc) and inform the manager/supervisor. A thorough history should identify: The nature of the alleged/suspected abuse. (Document explicit details identifying the abuse.) Environmental factors that increase risk Any previous CYF or New Zealand Police involvement. All current or previous contact with CDHB services. The abuse trend and whether it is increasing, decreasing or static. Ref: 0928 Page 3 of 25

4 The safety of children if the patient is an adult where care and protection concerns are identified. Vulnerability of the child (e.g. access to the child by alleged perpetrator or child very young/disabled, family or other support people will keep the child safe). Potential supports that are in place to keep the child safe, e.g. visits by community services, family or other support people. Consider: Risk of self-harm or suicide for child or parent/caregiver. Co-occurrence of partner abuse. If child abuse is suspected, assess the mother for partner abuse. Do not ask about partner abuse if another adult or child aged over three years is present. Co-occurrence of sibling abuse When a child presents with an injury, a comprehensive history should be taken by the appropriate CDHB staff member. If an injury is not adequately explained i.e. No history available Varying or changing history Delay in seeking medical advice History does not explain injury type History not consistent with developmental level and /or injury requires further assessment the on-call paediatrician should be contacted. If a medical examination is required, consent by the competent child (regardless of age) is required before any examination is undertaken (see CDHB Informed Consent Policy). Talking with children Do not attempt an in-depth interview of a child especially regarding sexual abuse. Please refer to Appendix Safety Planning /Intervention Emergency / Urgent Situation In an emergency or urgent situation, the following protocols apply: Ref: 0928 Page 4 of 25

5 The safety of staff and patients is paramount. If a child abuse incident places staff, patients or the child in a situation that either will or is likely to cause them serious and immediate harm, staff should get the assistance of: Hospital Security Telephone 777 if ringing from hospital premises. The New Zealand Police Telephone for external calls to the Police as is appropriate to the situation. Manager/Supervisor. be notified. This is a 24 hour service and staff should consult with and inform the duty Social Worker of the situation. Notification to CYF should be made by the key clinical worker where possible. Phone: 0508 FAMILY / Fax: Where there are serious care and protection concerns for a child, notify the contract centre by phone first followed by a written (faxed or ed) report. Note that there is no issue of breach of confidentiality. The CYP&F Act provides specific protection from legal action to anyone reporting to CYF in good faith. All written notifications should be made on the Child Youth and Family Referral Documents (Appendix 8) Staff do not need to discuss concerns with the child s parents or caregivers where it is believed that: it will place either the child or you, the health care provider, or the service in danger the family may close ranks and reduce the possibility of being able to help a child the family may seek to avoid statutory intervention. The child has been physically or sexually abused. There is immediate danger of death or harm. The child/children are home alone under 14 Note: Stay with the child/children until the Police arrive. There is immediate and serious risk to the child, or the environment to which the child is returning places the child at serious risk. Your safety is compromised. Ref: 0928 Page 5 of 25

6 If an injury is not adequately explained (no history available, history does not explain injury type, history not consistent with developmental level) and/or injury requires further assessment, the on-call paediatrician should be contacted. Inform key clinical staff as soon as is practicable. Where possible refer urgently to Social Work, or Case Manager who will assess the risk to the child, or consult with the Child and Family Safety Service and or Mental Health Child Protection Coordinator for advice. Record your concerns in the patient s clinical records or other appropriate CDHB records (as per Divisional Policy). Refer the case promptly to the Child and Family Safety Service or the Mental Health Child Protection Coordinator. The case may then be discussed at the next Child and Family Safety Review Committee/Child Protection Advisory Committee meeting. Inpatient Safety Planning / Intervention When a child has been or is likely to be seriously abused while the child is an inpatient, plans must be made and implemented to ensure the child s safety. This includes consideration of appropriate patient mix within the ward setting. Staff should: Make provision for the immediate safety of the child until a plan between CYF and the CDHB can be implemented. CDHB staff apart from mental health staff should refer to the Safety of Children in Hospitals protocol between CYF/ Police and the CDHB 2008 Follow divisional protocols re safety planning and consult senior clinical staff, management, key clinical staff and security for advice Refer to CYF and/ or Police as appropriate Ensure continuing assessment and inter-disciplinary / interagency consultation occurs. This includes the instigation of strategy meetings and the development and implementation of a Multi- Agency Safety Plan (MASP). Agree and document a decision on who will be responsible for any communication with the family/whanau. This may vary between services and cases (see divisional/department specific policies). Ideally communication with family/whanau should not take place before consulting with senior staff within your practice setting. Non Emergency/Urgent Situations of Child Abuse or Neglect Inform key clinical staff. Ref: 0928 Page 6 of 25

7 Where possible refer to Social Work or Case Manager who will assess the risk to the child, or consult with the Child and Family Safety Service and /or Mental Health Child Protection Co-ordinator for advice in a timely manner. appropriate CDHB records (as per department policy). If an injury is not adequately explained (no history available, history does not explain injury type, history not consistent with developmental level) and /or injury requires further assessment the on-call paediatrician should be contacted. Refer the case promptly to the Child and Family Safety Service or the Mental Health Child Protection Coordinator. The case may then be discussed at the next Child and Family Safety Review Committee/Child Protection Advisory Committee meeting. Death of a Child and Sibling Assessment In the event that a child is brought into the DHB and is deceased on arrival or the child dies in the DHB and the cause of death is suspicious, then an assessment of the safety of any siblings should be urgently undertaken. The Paediatrician on-call / Social Worker should determine if there are other siblings and if so report to CYF /Police. Family Safety and Security process At times it may be necessary to suppress patient details and or provide secure processes at the time of discharge. The guidelines for use when staff assess the safety of a victim of abuse to be high risk are outlined in Appendix Documentation All verbal reports, observations of abuse and risk factors that raise care and protection concerns will be fully and accurately recorded in the clinical record with the date, time, name, signature and designation as per CDHB documentation standards (as per Divisional Policies). All care and protection concerns will be electronically referred to the Child and Family Safety Service/Child Protection Coordinator where possible. Where the referrer is unable to refer electronically the appropriate paper based referral form should be used as per divisional procedures. Document facts and observations as soon as possible after the event or discussion in the clinical file. The following general principles apply: Ref: 0928 Page 7 of 25

8 Record facts and/or observations. Detail date, time and who was present at the time of the event. Clearly differentiate between what was seen and heard and what was reported or suspected and by whom. Where there has been a disclosure or a verbally abusive exchange, write what was said in quotation marks (verbatim) when possible. A body diagram can be used to record bruises cuts and other injuries. Any stated opinion (e.g. likely inflicted injury) must be based on facts. Document any actions including the names and details of anyone you have consulted with and the advise you were given. Document the outcome, the plan that was agreed after consultation and the steps taken to ensure the safety of the child. Sign the clinical notes and record legibly below the signature your name, designation and contact details Reporting or Referral Referrals to CYF and the Police can be made by telephone but must be followed by a faxed written report (see Appendix 8 for CYF referral template). When it is identified that a child has been or is likely to be abused, consideration must be given to the care and protection needs of siblings and appropriate referrals should occur where this is deemed necessary. If following a risk assessment and appropriate consultation child abuse or neglect is identified or suspected, then the child/ren should be reported to CYF or the Police as identified in the Emergency/ Urgent and Non Urgent procedure. 1.3 Staff Support and Safety In any case where staff have been involved in the reporting and/or management of abuse or neglect they should have opportunity for peer support/clinical supervision. This support should be sought from a colleague/clinician, Child and Family Safety Service/Mental Health Child Protection Coordinator, Line Manager or EAP Services Counsellor who has received appropriate training. (CDHB Volume 2 Legal and Quality Incident Management) Ref: 0928 Page 8 of 25

9 Procedure Owner Date of Authorisation Child Protection Service XXXXXX Ref: 0928 Page 9 of 25

10 1.4 Appendix 1: Child Abuse Management Flowchart Child/Young Person, or Child/Young Person of adult patient for whom staff have actual or potential care and protection concerns presents Assess for co-existence of partner abuse as per CDHB Partner Abuse Policy. Follow CDHB Partner Abuse Policy and the six step intervention process Report to immediate supervisor/manager involved No Is the child at immediate risk? Yes Refer to Social Work/Case Manager. Consult with the Child &Family Safety Service or Mental Health Child Protection Coordinator in a timely manner. Refer to C&FSS /CPAC via electronic referral /paper based referral form Case discussed at C&FSRC/CPAC meeting if it is deemed appropriate If adult/child or staff are in immediate or imminent danger contact the Police/Security via operator Inform and consult with key clinical staff Notify CYF Contact Centre Notify CYF Contact Centre Refer to C&FSS /CPAC via electronic referral /paper based referral form for direction Recommendation made re further action and who will complete tasks C&FSRC/CPAC to review situation when needed re CYF response and/or ongoing risks Ref: 0928 Page 10 of 25

11 1.5 Appendix 2: Definitions Child In this document the word child refers to child/tamariki and young persons/rangatihi aged 0-16 inclusive and the unborn child. Child Abuse Refers to the harming (whether physically, emotionally, or sexually), ill treatment, abuse, neglect or serious deprivation of any child/tamariki, young persons/rangatihi (Section 14b Children, Young Persons and Their Families Act 1989). This includes actual, potential and suspected abuse. Child Protection Means the activities carried out to ensure the safety of the child/tamariki, young persons/rangatihi in cases where there is abuse or risk of abuse/neglect. Child in Need of Care or Protection See Section 14 of the Children, Young Persons and their Families Act Emergency A situation in which harm is currently happening and the child is at serious risk. Emotional/Psychological Abuse Any act or omission that results in impaired psychological, social, intellectual and/or emotional functioning and development of a child. Neglect Any act or omission that results in impaired physical/psychological functioning and/or development of a child. Physical Abuse Any act or acts that may result in inflicted injury to a child. Sexual Abuse Any act or acts that result in the sexual exploitation of a child, whether consensual or not. Suspicion of Abuse Concerns for the child well being are based on concern from staff observation of signs of abuse, prior situations of risk, or reports from others. Ref: 0928 Page 11 of 25

12 Urgent Situation A situation in which the risk of the child being seriously harmed appears imminent or highly likely given the circumstances. Ref: 0928 Page 12 of 25

13 1.6 Appendix 3: Role of CFSRC (Child and Family Safety Review Committee), CPAC (Child Protection Advisory Committee), Child Youth and Family and the New Zealand Police CFSRC and CPAC CFSRC and CPAC receives and discusses referrals; provides education, consultations and information for individuals/teams; makes recommendations for action; follows up on referrals where indicated. Child Youth and Family A service of the Ministry of Social Development that carries out the legislative requirements of the Children, Young Persons and Their Families Act Responsibilities are: To investigate cases of actual and suspected child abuse and/or neglect. To complete evidential interviews in co-operation with NZ Police. NZ Police Government agency responsible for: Working co-operatively with Child, Youth and Family in child abuse and/or neglect protection work. Investigating cases of abuse and/or neglect where an offence has or may have been committed. Prosecuting offenders where an offence has been committed. Accepting reports of suspected abuse and or neglect and referring these to Child, Youth and Family. Ref: 0928 Page 13 of 25

14 1.7 Appendix 4: Four Recognised Categories of Child Abuse These frequently overlap in individual cases. Refer to the Recognition of Child Abuse and Neglect published by the Risk Management Project, Children, Young Persons and Their Families Agency Physical Abuse Child physical abuse is any act or acts that result in inflicted injury to a child or young person. It may include, but is not restricted to: Bruises and welts Cuts and abrasions Fractures or sprains Abdominal injuries Head injuries Injuries to internal organs Strangulation or suffocation Poisoning Burns or scalds Non organic failure to thrive Fabricated or induced illness by carers 2. Sexual Abuse Child sexual abuse is any act or acts that result in the sexual exploitation of a child or young person, whether consensual or not. It may include, but is not restricted to: Non-contact abuse: Exhibitionism Voyeurism Suggestive behaviours or comments Exposure to pornographic material Inappropriate photography Contact abuse: Touching breasts Genital/anal fondling Masturbation Oral sex Object or finger penetration of the anus or genitalia Penile penetration of the anus or genitalia Ref: 0928 Page 14 of 25

15 Encouraging the child to perform such acts on the perpetrator Involvement of the child in activities for the purposes of pornography or prostitution. 3. Emotional/Psychological Abuse Child emotional/psychological abuse is any act or omission that results in impaired psychological, social, intellectual and/or emotional functioning and development of a child. It may include, but is not restricted to: Rejection, isolation or oppression. Deprivation of affection or cognitive stimulation. Inappropriate and continued - criticism, threats, humiliation, accusations, expectations of, or towards, the child. Exposure to family violence. Corruption of the child through exposure to, or involvement in, illegal or anti-social activities. The negative impact of the mental or emotional condition of the parent or caregiver. The negative impact of substance abuse by anyone living in the same residence as the child. 4. Neglect Child neglect is any act or omission that results in impaired physical functioning, injury, and/or development of a child. It may include, but is not restricted to: Physical neglect - failure to provide the necessities to sustain the life or health of the child. Neglectful supervision - failure to provide developmentally appropriate and/or legally required supervision of the child, leading to an increased risk of harm. Medical neglect - failure to seek, obtain or follow through with medical care for the child resulting in their impaired functioning and/or development. Abandonment - leaving a child in any situation without arranging necessary care for them and with no intention of returning. Refusal to assume parental responsibility - unwillingness or inability to provide appropriate care or control for a child. Educational Neglect failure to provide a child with access to education Ref: 0928 Page 15 of 25

16 1.8 Appendix 5: Legal and Privacy Issues Since the introduction of the Privacy Act 1993 and the Health Information Privacy Code (1994), agencies and individuals have become concerned about how much information can be given to statutory social workers or the Police. Both documents make provision for the disclosure of information necessary to prevent harm to any individual. Privacy restrictions are over-ridden by certain sections of the Children, Young Persons and Their Families Act These provide for the reporting of child abuse and neglect and protection of an individual from proceedings when disclosing child abuse to either a statutory social worker or police, and government agency obligations. Health workers therefore, are able to give information to the Child, Youth and Family or Police, both by reporting abuse or when requested by either agency. Children, Young Persons and Their Families Act 1989 S15 Reporting of ill treatment or neglect of child Any person who believes that any child or young person has been, or is likely to be, harmed (whether physically, emotionally, or sexually), illtreated, abused, neglected, or deprived may report the matter to a social worker or a member of the police. S16 Protection of person reporting ill treatment or neglect of child or young person No civil, criminal, or disciplinary proceedings shall lie against any person in respect of the disclosure or supply, or the manner of the disclosure or supply, by that person pursuant to section 15 of this Act of information concerning a child or young person (whether or not that information also concerns any other person), unless the information was disclosed or supplied in bad faith. S66 Government Departments may be required to supply information Every Government Department, agent, or instrument of the Crown and every statutory body shall, when required, supply to every Care and Ref: 0928 Page 16 of 25

17 Protection Co-ordinator, social worker, or member of the police such information as it has in its possession relating to any child or young person where that information is required: 1. For the purposes of determining whether that child or young person is in need of care or protection (other than on the ground specified in section 14 (1)(e) of this Act); or 2. For the purposes of proceedings under this part of this Act. Privacy Act 1993 Principle 11 (f) (ii) An agency may disclose information if that agency believes, on reasonable grounds that the disclosure of the information is necessary to prevent or lessen a serious and imminent threat to the life or health of the individual concerned or another individual. Health Information Privacy Code 1994 Rule 11 subsection 2 (d) (ii) An agency that holds personal information must not disclose the information to a person or body or agency unless the disclosure of that information is necessary to prevent or lessen a serious and imminent threat to the life or health of the individual concerned or another individual. Health Act 1956 Section 22 (2) Disclosure of health Information Any person being an agency, that provides health services or disability service may disclose health information to a social worker or a Care and Protection Co-ordinator within the meaning of the Children, Young Persons and Their Families Act (1989), for the purposes of exercising or performing any of that person s powers under that Act. Ref: 0928 Page 17 of 25

18 1.9 Appendix 6 What to do when a child tells of his or her abuse Five Basic Rules: Listen to what they say. Say you re glad they told you. Say you re sorry it happened. Let them know it s not their fault. Let them know you ll help. Listen Avoid in depth questioning. Allow the child to tell only as much as they want. Take note of what the child has actually told you and write down what it was the child actually said. Do not over react A child s initial disclosure of abuse is a critical moment. He or she will be monitoring your reaction. Do not panic If the child judges you unable to manage the situation, he or she may not disclose further. Do Support If appropriate, let them know that they re not the only one that this sort of thing happens to that it happens to other children sometimes. Seek advice and assistance Inform key clinical staff (Paediatrician, Psychiatrist, Social Worker, Case Manager etc.). The CDHB Child and Family Safety Service ( ) and or Mental Heath Child Protection Co-ordinator Protection Service is available for consultation. CYF (0508 FAMILY) and the Police Child Abuse Unit ( ) can also assist. Ref: 0928 Page 18 of 25

19 1.10 Appendix 7 Safety and Security Guidelines This guideline sets out the CDHB procedures when there are: confidentiality issues or a need to access increased support to optimise the safety of child and or caregivers and /or when the risk to the safety of child and or caregivers is assessed to be at very high risk. Whenever practicable and appropriate the procedures outlined should be discussed with the child s caregiver and their consent obtained. The safety of the child and or their family/whanau is the paramount consideration. When a child and or their family/whanau expresses fear of an (alleged) abuser or others they must be taken seriously. In this case it is defensible for health care professionals to refuse public access to patient/client information and to facilitate the child and their family/whanau leaving the health setting via a safe exit for a place of safety. The below procedures are dependent on the type of Patient Management System services use and include Homer, SAP and CareSys. 1. HOMER Procedure to establish patient/client information suppression The child and their family/whanau discloses to the staff member concerns around their safety. Refer to Child and Family Safety Service and or Mental Health Child Protection Coordinator at the earliest opportunity if access to a social work service isn t available. The staff member discusses with the child and their family/whanau the potential to suppress patient s/client s details from being released publically consent to proceed is given by patient/client/caregiver and or guardian as appropriate. The admitting clerk/ward clerk is informed and places a No details to be released which places a red flashing code on the Patient s Condition Screen of Homer and also the switchboard screen. The clerk enters an appropriate code (1, 2 or 3) on to the confidentiality field on the Patient Condition Screen and will ensure details are accurate. Ref: 0928 Page 19 of 25

20 The legal name of the patient/client remains as a true and accurate record on the clinical record. Babies admitted with a patient/client should similarly have their details suppressed. The information on the PMS will not be changed when patient/client is discharged. 2. SAP and CareSys Procedures for name suppression and pseudonym addition: The child and or their family/whanau discloses to the staff member concerns around their safety Refer to Child and Family Safety Service and or Mental Health Child Protection Coordinator at the earliest opportunity if access to a social work service isn t available. The staff member discusses with the patient/client/caregiver/guardian the potential to suppress patient s/client s details from being released publically consent to proceed is given by patient/client/caregiver and or guardian as appropriate. Complete disclosure options (full, none or partial) Gain patient/client/caregiver and or guardian s instructions regarding partial disclosure. Babies admitted with a patient/client should similarly have their details suppressed. Should it be deemed necessary, complete documentation to give the patient a pseudonym Upon discharge, complete documentation to change patient/client name back to their legal name 3. Non disclosure of patient/client information Inform the enquirer that patient/client details are not able to be provided. Ask for the caller s name and record if provided. Notify the key nurse/person responsible for the child /patient s/client s care. Notify CDHB Security (if applicable) if for protection reasons the caller is the (alleged) abuser and if Police follow-up is likely. 4. Procedure used to discharge child /patient/client in a safe manner from a health setting when high-risk safety issues exist: Ref: 0928 Page 20 of 25

21 The key worker or Social Worker must liaise with CYFS to arrange the Multi-Agency Safety Plan (MASP)/discharge plan in consultation with the patient/client/caregiver. This procedure also applies if the child is being discharged into the care of CYF. A clear and detailed discharge plan will be discussed with the staff members from the DHB service. The MASP/discharge plan may include the child/caregiver leaving the health setting escorted by a security and or police via a safe exit. Ensure the appropriate clinical staff are informed of the MASP/discharge plan process and the following as appropriate: Senior Manager Police CDHB Security (if available in work area) Ensure the discharge plan is included in the Multi-agency Safety Plan and Family Violence Preliminary Risk Assessment Form as appropriate. Advise senior staff member of the discharge outcome. Note: Consult with a senior staff member whether a Quality Improvement Event Reporting Form should be completed for situations when extreme risk, danger etc is involved. Ref: 0928 Page 21 of 25

22 1.11 Appendix 8 CYF Notification Template Referral to Child Youth & Family Call Centre Telephone Toll Free or 0508 Family Fax (09) Type of Abuse (please identify category/categories.) Physical Sexual Emotional Neglect Other FOR EACH CHILD BEING REFERRED PLEASE SUPPLY FULL CONTACT DETAILS INCLUDING: Child s Name: DOB Address Mother: Address Father: Address Step Parents: Current Caregiver: Siblings: (Full names, dates of birth, schools, address(es) if different from child s) Ref: 0928 Page 22 of 25

23 Other Members of Immediate Household: (relationship to child) Other Family/Whanau: (Full name, age, address, contact telephone number, contact person): Pre-School / School: (Address, contact telephone number, contact person): Other Agencies involved with child and child s family: (Address, contact telephone number, contact person): Medical & Social Work Contacts at Agency: (Names, contact telephone/locator numbers) REASON FOR REFERRAL Background: (Relevant child / family medical and social history, other background matters of importance to investigation of abuse or neglect.) To your knowledge, has CYF had previous involvement with this child or member of its family? Please give details. Ref: 0928 Page 23 of 25

24 MEDICAL REFERRAL Is the child / young person a: (please circle) Current In-patient Current patient not admitted Other IS CYF REQUESTED TO ATTEND A DISCHARGE / PLANNING MEETING? YES- Date Time Venue Ref: 0928 Page 24 of 25

25 WHAT SERVICES EXACTLY DO YOU ENVISAGE CYF PROVIDING? PLEASE BE SPECIFIC: Your Name: Designation: Service / Group: Address, usual contact numbers: WHERE CAN YOU BE REACHED NOW? Confidentiality Required Yes Date: Signed: Ref: 0928 Page 25 of 25

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