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Form 1: Meitheal Request Form Confidential: 1. Child or Young Person

This document is a request form for a Meitheal meeting to address the needs of a child or young person. It collects information about the child, parents/guardians, and the primary and secondary reasons for the request. The lead practitioner submitting the request provides their contact details and sector. Parents are asked to consent to information being collected and shared for the Meitheal process, and potentially anonymized for research. They also agree their child will be involved and understand how their information may be used.

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306 views2 pages

Form 1: Meitheal Request Form Confidential: 1. Child or Young Person

This document is a request form for a Meitheal meeting to address the needs of a child or young person. It collects information about the child, parents/guardians, and the primary and secondary reasons for the request. The lead practitioner submitting the request provides their contact details and sector. Parents are asked to consent to information being collected and shared for the Meitheal process, and potentially anonymized for research. They also agree their child will be involved and understand how their information may be used.

Uploaded by

tqsnr
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Form 1: Meitheal Request Form Confidential

1. Child or young person


Meitheal ID number: CFSN area:
First name: Surname: Sex: Date of birth: (DD/MM/YY)

M F

Number, street
Town:
or townland:
Pre-school, school or
County:
other education centre:
Nationality: Ethnicity:
First language of the First language
child or young person: of the parent:
Is an interpreter required for this Meitheal process? (tick one) Yes No

If Yes, is the family already using an interpreter in accessing another service? (If so, provide details)

2. Parents and guardians


First name: Surname: Relationship to the Is this person the Contact telephone
child or young legal guardian? number:
person: (tick one)

Yes No

Yes No

Yes No

Number, street
Address (if different from above)
or townland:
Town: County:

3. Reason for request


Note: You do not have to rate all the needs listed below, just the needs that are an issue for this child or young person
a) On a scale of 1-10 please rate to what extent the child or young person’s needs are being met now (10 means ‘fully’
and 1 means ‘not at all’).
b) In the outcome column please identify what you would like to be different for the child or young person.
Rating Outcome
1. Emotional issue
2. Behavioural issue
3. Physical illness / disability
4. Mental health issue
5. Learning disability
6. Addiction
7. Education issue (for example:
attendance)

8. Family issues (for example:


bereavement)

1
9. Social isolation
10. Parenting support
11. Financial / housing difficulties
12. Relationship issues
13. History of domestic violence
14. Other
Please provide further details about ratings and outcomes if it is necessary:

From the list above what are the primary and secondary reasons for this Meitheal request:
Primary reason: Secondary reason:

4. Lead practitioner
Name: Contact telephone
numbers:
Address: Agency or service:

Sector: (for example,


health, education,
community or
voluntary)
Email Profession or
address: discipline:
Lead practitioner signature: Date:

5. Parent’s request for support and consent to information storage


I agree to the statements below.
1. My child will be involved in this Meitheal.
2. Practitioners and other professionals may use the information gathered by this Meitheal process to help provide
services to me and to my child. I understand how this information may be used.
3. This information may be shared between the Child and Family Support Network Coordinator and the Children and
Families Social Work Service on a need-to-know basis. They will share this information to ensure that Meitheal is
the correct response for my child.
4. If there are any concerns about the safety and welfare of a child, practitioners and other professionals must follow the
Children First national guidance and legislation to protect the child.
Anonymised information is information that does not include anything
that will identify a specific person. Researchers may use anonymised Yes No
information from this form to improve services for children.
First name: Surname: Relationship to child: Signature: Date:

First name: Surname: Relationship to child: Signature: Date:

Please return this form to the Child and Family Support Network Coordinator.

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