ESCS Form R08 - Provision Placement Request (3)

ESCS Form R08 - Provision Placement Request (3)
Person completing this form

First NameLast Name
Email
example@example.com
Date

DayMonthYear
Date
Date

DayMonthYear
Name of Young Person

First NameLast Name
Date of Birth

DayMonthYear
Date
Does this person have a DOL*

YesNoOther
Date Placement Required

DayMonthYear
Date
Court of Protection DOL*

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Cancelof
Ofsted have been made aware that ESCS are unregulated and this is an emergency/crisis situation*

YesNo
PLEASE CONTACT OFSTED / YOUR LEGAL TEAM AND GAIN AUTHORISATION THAT THIS PERSON CAN BE PLACED WITHIN OUR UNREGULATED SETTING
Risk Assessment

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Cancelof
Care or Support Plan

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Cancelof
Placement Enquiry Form

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Cancelof
Birth Certificate

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If this cannot be supplied please advise where we can obtain Cancelof
Number of Day Staff*
Number of Waking Night Staff*
Number of Sleeping Night Staff*
Weekly allowance*
How is the weekly allowance obtained*
Contact emails to receive reports*
Please include all stakeholders that require access to daily reports
Name / Job Title / Contact Numbers of persons involved in the provision*
i.e social worker/ advocate / EDT / CAMHS
Observation Levels*

Arms LengthLine of SightUnsupervisedOther
Please explain requested observation levels further*
Permitted contact list*
i.e parents, grandparents, friends
Non-permitted contact list*

Restrictions*

	Not Allowed	Supervised	Allowed
Please mark under the heading that best fits your child
1. Access to Mobile Phone
2. Access Internet
3. Smoking
4. Control of personal funds
5. Access to sharps
6. Access to aerosols
7. Access to bank card
8. Access to Games console (Xbox)
9. Games console to have internet access
10. OCULUS with Internet access
11. OCULUS without Internet access

Other restrictions not listed*
Known medication and dosage and medical issues*
I have the authority to make this request and understand that bank holidays will be charged at double time.*

I agree
Should be Empty: