Emergency Place Of Safety (EPOS) Cork

1. Network & Approval Details

Referring Social Work Department *

Name of Team within Network *

Is this referral approved by Tusla Gatekeeper? *

Date of Referral *

2. Child & Professional Details

Child's Name *

Child's DOB *

Social Worker's Title *

Social Worker Name *

Social Worker's Mobile *

Social Worker's Email *

Social Work Team Lead Email

3. Care Status & Placement History

Is this Referral regarding a Child In Care? *

Current Care Status

Current Arrangement

Risk of SEA at Referral?

How many placement moves has this child had?

How many moves due to disruption meeting?

4. Parent/Carer & Health Details

Parent/Carer's Names *

Parent/Carer Contact Number's *

Parent/Carer's Address

Eircode / Postcode *

GP Name & Address

Is Child in Education?