Attachment & Trauma Informed Assessments Form

Referral Submitted

Thank you - your Attachment & Trauma-Informed Assessment referral has been received by the HAPii team.
We will be in touch within 2 working days to discuss scope, documents, consent, and next steps.

Referral Details

Date of Referral *

Preferred Contact Method *

Level of Urgency *

Relevant Deadline / Hearing Date

Referring Person / Organisation

Name *

Position / Role *

Organisation / Agency *

Contact Phone *

Contact Email *

Assessment Requested

Attachment-Informed Assessment Focused on attachment history, caregiving relationships, relational presentation, and care-planning needs. Trauma-Informed Assessment Focused on trauma history, presentation, regulation, triggers, strengths, and support needs. Combined Attachment & Trauma-Informed Assessment Integrated assessment of attachment, trauma, developmental needs, risk, and therapeutic recommendations. Consultation / Review A specialist review of existing records, reports, or care-planning questions.

Primary Purpose of Assessment *

Child / Young Person Details

Name(s), Date(s) of Birth & Age(s) *

Current Placement / Living Arrangement *

Legal Status / Care Order

Communication, Disability, Cultural or Access Needs

Family, Carers & Network

Birth Parent(s) / Legal Guardian(s) *

Current Carer(s) / Key Adults *

Siblings / Significant Relationships

Current Contact / Access Arrangements

Background & Presenting Concerns

Reason for Referral *

Known Attachment / Caregiving History *

Known or Suspected Trauma History *

Current Presentation / Behavioural and Emotional Needs *

Child's Strengths, Interests & Protective Factors

Risks, Safeguarding & Court Context

Immediate Risk / Safety Concerns? *

Court / Legal Proceedings Involved? *

Risk / Safeguarding Details

Current Supports & Previous Work

Current Professional Supports

Previous Assessments / Interventions

Specific Questions for HAPii to Address

Documents Available

Care Plan Chronology Previous Assessments Court Reports / Orders School / Therapeutic Reports Consent Forms Other

If other, please specify

Preferred Consultant

Declaration

I confirm I have authority to make this referral and that consent, information-sharing permissions, and safeguarding arrangements are in place or will be clarified before assessment begins. I understand HAPii may request further documents before confirming the scope of work.

Additional Notes

Signature (Full Name) *

Date *

HAPii Attachment & Trauma-Informed Assessment Form

Referral Submitted