N.B: TO BE COMPLETED IDEALLY BY THE TIME THE CHILD IS 27 MONTHS AND NO LATER THAN 35 MONTHS
Part 1
All about
me and my family!
PART
1
at
My
Portrait
at Two
Development Matters
Making relationships
Self-confidence and self-awareness
Managing feelings and behaviour
How I like to play and learn
(including my likes and dislikes)
Insert Photo
How I Communicate
My Communication and Language
My Physical Development
Name:
My Personal Social and Emotional
Development
Child’s Name
DOB
Age in months
Date of assessment
Development Matters
Moving and handling
Health and self-care
Name of setting
Development Matters
Listening and attention
Understanding
Speaking
Agreed actions to be taken by the early years setting, parent/carer and health visitor (refer to home and setting)
PTO: PLEASE ENSURE THAT YOU COMPLETE THE REVERSE OF THIS FORM
(Autumn, 2016 version)
Part 2 (Insert original copy in Red Book, file 1 copy at setting)
Summary Information
Date of Integrated
Review at your
Setting
Circle which ASQ-3 was
completed by parent
(Integrated Review at EY
setting only)
Who was
present?
24 Months
27 Months
30 Months
Other (specify the age)
Outcomes of the review meeting discussion including ASQ-3 and My Portrait assessment (circle the most applicable)
Not yet meeting key milestones
Beginning to meet key milestones
Reaching key milestones
Actions
be support
taken by
professionals,
(including
referrals to other
agencies) No referral/signposting required
Referraltoand
plan
required
Signposting/monitoring
required
Where a referral is required, circle the service the referral is being made to
Area SENCO
Speech and Language Therapy*
First Steps /Psychology*
Special Advisory Clinic (via HV)
MAT*
1:1 Dietetics*
HENRY (Healthy Eating and nutrition for the
GP
Other (specify)
really young)
N.B. Please remember that referrals should be made to MAT on a CAF if there are two or more agencies involved or a child needs
support from two professionals e.g. speech and language therapist and HV.
Actions to be taken by professionals, if applicable (including signposting and referrals to other agencies to support the
child and family)
Action
Who will take the action
e.g. who will make the
referral?
When will it be
done?
When will the outcome of the
action be reviewed and by
whom?
N.B. Referral form to be completed within 2 weeks of the Progress Check/27 month review meeting, keep a copy on file.
Parent /Carer Comments
Contributors
Parent / Carer Name_____________________________Signature ______________________
Date ______________________
Key Person Signature __________________________Link Health Professional Signature__________________________________
Other Professional’s Signature: ___________________________ Name of service:_______________________________________
My Portrait has been moderated by (name)_____________________________________ Signature __________________________
PLEASE NOTE: The information you have provided in this document will be attached to your child’s Personal Child Health Record (Red
Book). This information will also be shared with the Health Visitor and may be shared with other professionals if considered necessary
for the purpose of providing health and care services for your child. This information will also be used for statistical purposes and
will be anonymised if it is used outside of your child’s healthcare setting. By signing this form it is deemed that you understand and
consent to the ways in which this information will be used.
(Autumn, 2016 version)