LAC Notification Form (Regulation 41)

Full Name:	Insert recent photograph:
Other Name(s):
Date of Birth:	Click or tap to enter a date.
Gender:	Choose an item. If other, please state:
Current placement address and telephone number:	Full Name of Organisation: Address & Postcode: Telephone Number(s):
Placement start date:	Click or tap to enter a date.
Legal status S20 / S21 / S31 etc:	Young person’s mobile no:
Staff ratio:	Handset IMEI:
DESCRIPTION:
Ethnicity:	Choose an item.	Sub-Ethnicity	Choose an item.
First Language	Choose an item.	Fluency in English	Choose an item. If No: Interpreter required? ☐
Nationality:	Choose an item. If other, please state:	Country of Birth:	Choose an item.
Is the young person an Unaccompanied Asylum Seeker?	Yes No
Warning signs/Risks:
Religion:	Choose an item. Practising Religion? Tick box if yes: ☐ If other, please state:
Smokes: Cigarettes/ Cannabis/ E-Cigarette etc..?	Choose an item. If yes, provide details:	Drinks Alcohol:	Choose an item. If yes, provide details:
Uses drugs? Which drugs?	Choose an item. If yes, provide details:
Height:	Unique jewellery / possessions:
Build:	Hair colour:
Eye colour:	Accent:
Wears glasses:	Marks / scars / tattoos:
HEALTH:
Physical conditions:	Mental health conditions:
Communication difficulties:	Other conditions:
Habits:	Learning needs:
Essential medication:	NHS Number:

RESPONSIBLE LOCAL AUTHORITY:
Responsible Local Authority Name:	Team responsible:
OOH / Duty contact no:	Case reference:
SOCIAL WORKER’S DETAILS:
Name:	Address:
Telephone number(s):	Email:
SOCIAL WORKER’S TEAM MANAGER DETAILS:
Name:	Address:
Telephone number(s):	Email:
DOCTOR’S DETAILS:
Name:	Address:
Telephone number:	Email:
CONTACTS – FAMILY:
Name: Address: Telephone:
Name: Address: Telephone:

ANY RELEVANT RISKS. CONSIDER USE OF THE PHILOMENA PROTOCOL https://proceduresonline.com/trixcms1/media/12315/philomena-protocol-form-april-2022.docx
SAFEGUARDING AND SOCIAL CARE INFORMATION:	Yes	No	If Selected Yes, provide details:
Is the child subject to a child protection plan?
Does the child have a history of running away or missing from home?
Are there any concerns around CSE/CCE?
Is the child subject to any Court order or YOS intervention as a young offender?	If Yes: Specify which Youth Offending Service:
Has a risk assessment been completed?	If yes, specify what type of risk assessment: Risk Assessments/ Trigger Plans etc… to be emailed to the relevant Local Authority (details below) alongside this Reg41 Notification form.
Should the Police be informed of any risks?	If Yes: Specify the risks

Name of Staff completing form:	Date form completed:	Click or tap to enter a date.

END OF PLACEMENT – This section to be completed when the Young Person leaves the placement
Reason the placement ended:	End date of placement:	Click or tap to enter a date.
Forwarding address (if known):	Name of Staff completing form & Date form completed:	Click or tap to enter a date.

Once complete, please send this form to the relevant Local Authority:

Please use https://www.gov.uk/find-local-council to identify which Local Authority the Young Person is placed in. Please only contact the relevant Local Authority where the Young Person is residing, via the below email address.

Leicestershire County: NotificationsLAC@leics.gov.uk

Leicester City: Placements.Desk@leicester.gov.uk

Rutland County: Childrensreferrals@rutland.gov.uk

In ALL cases, The Reg41 LAC Notification form should always be sent to the following addresses:

Leicestershire Police: MPRU@leics.police.uk

Health: lep-tr.FYPClookedafterchildrennotifications@nhs.net