Form IC1 11/18
Part 1: Your details
Part 1: Your details. Part 1: Your details
Guidance: Please write in black ink and use CAPITAL LETTERS. Please now pass this form to the professional to complete Parts 2 and 3.
Part 1: Your details
Part 1: Your details. Name
Part 1: Your details
Part 1: Your details. National Insurance (NI) number
Part 1: Your details
Part 1: Your details. Address
Part 1: Your details
Part 1: Your details. Postcode
Part 2: Registered social worker’s contact details
Part 2: Registered social worker’s contact details. Part 2: Registered social worker’s contact details
Guidance: Parts 2 and 3 should be completed by a registered social worker you have previously spoken to or are now speaking with in their professional capacity about the circumstances in which you have taken on the care of the child. They’ll need to confirm that if this child were not being cared for by you, it is likely that they would otherwise be looked after by a local authority.
Part 2: Registered social worker’s contact details
Part 2: Registered social worker’s contact details. Name
Part 2: Registered social worker’s contact details
Part 2: Registered social worker’s contact details. Job title
Part 2: Registered social worker’s contact details
Part 2: Registered social worker’s contact details. Local authority
Part 2: Registered social worker’s contact details
Part 2: Registered social worker’s contact details. Phone number
Part 2: Registered social worker’s contact details
Part 2: Registered social worker’s contact details. Address
Part 2: Registered social worker’s contact details
Part 2: Registered social worker’s contact details. Postcode
Part 3: Registered social worker declaration
Part 3: Registered social worker declaration. Part 3: Registered social worker declaration
Guidance: Based on the meeting(s) I have had with the claimant in the course of my professional duties, and any other relevant information available to me, I confirm that:
Part 3: Registered social worker declaration
Part 3: Registered social worker declaration. The claimant has undertaken the care of the child who is normally living with them on an informal basis.
Options: Yes; No
Part 3: Registered social worker declaration
Part 3: Registered social worker declaration. The circumstances of the child are such that, if they were not in the care of the claimant, it is likely that they would otherwise be looked after by a local authority.
Options: Yes; No
Part 3: Registered social worker declaration
Part 3: Registered social worker declaration. Claimant’s name
Part 3: Registered social worker declaration
Part 3: Registered social worker declaration. contacted me on / /
Part 3: Registered social worker declaration
Part 3: Registered social worker declaration. Regarding the circumstances in which the child came to live with them
Part 3: Registered social worker declaration
Part 3: Registered social worker declaration. Child’s name
Part 3: Registered social worker declaration
Part 3: Registered social worker declaration. Child’s date of birth
Part 3: Registered social worker declaration
Part 3: Registered social worker declaration. The date the child came to live with the claimant
Part 3: Registered social worker declaration
Part 3: Registered social worker declaration. Any other information
Part 3: Registered social worker declaration
Part 3: Registered social worker declaration. Signature
Part 3: Registered social worker declaration
Part 3: Registered social worker declaration. Date / /
Part 3: Registered social worker declaration
Part 3: Registered social worker declaration. Registration number