Form 2: Meitheal Strengths and Needs Record Form Confidential1. Child or young personNote: Fill in a separate form for each individual child or young person.Meitheal ID num-ber:

First name: Surname: Date of birth: (DD/MM/YY)

2. Parents and guardiansFirst name: Surname: Relationship to the

child or young per-son:

Is this person the legalguardian? (tick one)

3. Other family members including brothers and sistersNote: To add more rows, click in the bottom right hand cell and press the tab key.

First name:

Surname: Relationship to the child or young person:

Where this person lives:

Date of birth:(DD/MM/YY)

If a child or young person, are they also subject to Meitheal?

4. Services supporting the child or young person and their family (Please tick the relev-ant columns)

Agency or service

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Name of key contact

Adult mental health services CAMHS (Child mental health) Crèche or childcare services Disability services Drugs and alcohol service

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Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Agency or service

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Name of key contact

Education welfare services Family resource centre Family support GP Home School Community Li-aison Coordinator or Schools Completion Project Coordinator

Housing service or local author-ity HSE early intervention team or school age team

Paediatric occupational therapy Paediatric physiotherapy Psychological service Speech and language therapy Juvenile liaison officer or gardaí National educational psycholo-gical service

Parent and toddler group Probation services Public health nurse School or training centre Social worker (medical, disability,mental health, primary care or other)

Sports clubs Tusla social work(initial assessment) Youth service including mentor-ing

Other

Has any other child or young person in the household ever received a service from any of the above?(If yes, please give details below)

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5. Identifying strengths and needs5.1 Active and healthy

Physical health Healthy choices Use of drugs and alcohol Play, hobbies, sports and being out-

doors Limit on daily screen time

Mental health Happy and good coping skills Aids and barriers to happiness and

coping Sexual behaviours Disability that affects wellbeing

StrengthsParent or guardian’s view:

Child or young person’s view:

NeedsParent or guardian’s view:

Child or young person’s view:

5.2 Achieving in all areas of learning and development

Going to school or training Attitude towards school and learning Learning and developing

Getting on with others Aids and barriers to getting on with

others Confidence and responsibility

StrengthsParent or guardian’s view:

Child or young person’s view:

NeedsParent or guardian’s view:

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Child or young person’s view:

5.3 Safe and protected from harm Safe at home Supportive family, neighbours and

friends People to talk to when upset Safe from bullying Supervised while online

Accepted for who they are Neighbourhood environment Peer groups and social networks Aware of danger and how to keep safe

StrengthsParent or guardian’s view:

Child or young person’s view:

NeedsParent or guardian’s view:

Child or young person’s view:

5.4 Economic security and opportunity

Enough money for food, clothes and other every-day items

Aids and barriers to achieving goals

Opportunities for the future Goals for the future

Strengths

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Parent or guardian’s view:

Child or young person’s view:

NeedsParent or guardian’s view:

Child or young person’s view:

5.5 Connected, respected and contributing to their world Aware of background including religion and

culture Aids and barriers to belonging in the com-

munity

Involvement in local groups and re-sources

Aware of rights and responsibilities

StrengthsParent or guardian’s view:

Child or young person’s view:

NeedsParent or guardian’s view:

Child or young person’s view:

6. Summary of needs and outcomes (What difference would you like to see for your child?)Parent or guardian’s viewNeeds Outcomes Child or young person’s view

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Needs Outcomes

7. Next steps – please tick the relevant box1. Proceed to Meitheal support meeting2. Close Meitheal process and record reasons for closure in Form 4 Closure and

Feedback3. Other (please ex-plain)

What is the best day and time for parents or guardians and the child or young person to attend

8. Agreement to participate in Meitheal meetingsNote to lead practitioner: Please ensure the Strengths and Needs Form is only shared with agencies that parents or guardians have consented to.1. I agree that my child will be involved in this Meitheal.2. I agree that this information be stored and used to provide services to myself and my child.3. I agree that the following individuals or agencies will be involved in the Meitheal support

meetings and I understand that this information will be shared with the relevant agencies as agreed.Anonymised information collected in this form may be used for

research: Name Agency or service Contact details Child or young person sig-nature: Dat

e:

Parent or guardian signa-ture: Dat

e:

Parent or guardian signa-ture: Date

:

Lead practitioner signa-ture: Date

:

Please return this form to the Child and Family Support Network Coordinator. Note that at least one parent or guardian and the lead practitioner must sign this form before it can be accepted by the CFSN coordinator.

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Yes No