1.	Child/young person's name:

2.	Name of Short Break Carer:

3.	What has improved since the last review?

4.	Have there been any areas of difficulty?
	Yes
	No

	If yes please explain

5.	Do you, as the carer, feel you meet the child/young person's needs?

6.	What goals have been achieved?

7.	Are there areas of the child/young person's behaviour that you could do with further information about?
	Yes
	No

	If YES please explain

8.	What activities has the child/young person taken part in?

9.	Are there any difficulties when you are out and about? in relation to....
		YES		NO
	Mileage allowance	Mileage allowance YES		Mileage allowance NO
	Blue Badge	Blue Badge YES		Blue Badge NO
	Entrance fees	Entrance fees YES		Entrance fees NO
	Pocket money	Pocket money YES		Pocket money NO

10.	Are there arrangements between families in place regarding the above?
	YES
	NO

11.	Do you give medication?
	YES
	NO

12.	Do you record this?
	YES
	NO

13.	Are the correct procedures in place?
	YES
	NO

14.	Are there any issues around health and safety in relation to the child/young person or equipment?
	YES
	NO

	IF YES PLEASE EXPLAIN

15.	Do you know the long term plans for the child/young person?
	YES
	NO

16.	Do you feel your relationship with the primary carer is positive?
	YES
	NO

	If YES explain how this has been achieved, or if NO, please explain the difficulties.

17.	What should change in relation to the placement and plan for the child/young person and what should stay the same?

18.	Are there any other ideas we could explore or try?

19.	Do you feel you have enough support from your supervising social worker?
	YES
	NO

20.	Do you need any help with training and resources to manage the placement?
	YES
	NO

	IF YES PLEASE EXPLAIN

21.	Do you feel your views are listened to and actioned?
	YES
	NO

22.	Would you like a visit from the Independent Reviewing Officer (IRO)?
	YES
	NO

23.	The child/young person's Social Worker is:

24.	Please enter the date you completed this form.