Multi Agency Referral Form (MARF) STRICTLY CONFIDENTIAL
Better Together for Children
www.wlscb.org.uk
Multi-Agency Confirmation of Referral to Walsall’s Children’s Services Initial Response Service – Multi Agency Screening Team (MAST)
This form should always be completed by all agencies when making a referral to Walsall Children’s Services Initial Response Team - MAST. This is to allow the sharing of information with other agencies and secure the appropriate response. All urgent child protection referrals should in the first instance be made by telephone to the MAST – 01922 658170/Out of Hours 0300 555 2922 or 0300 555 2836 - In an emergency call the Police on 999.
Contact should then be confirmed in writing as soon as possible and within 24 hours, using this form. Concerns should be discussed with the child’s parents, making them aware that a referral to the MAST has been made, unless to do so would place the child at risk of significant harm, or any other individual at risk of serious harm, or lead to interference with any potential investigation. The child’s safety and well-being must be the overriding consideration in making any such decisions.
Prior to submission, all referrals should be discussed within the referring agency in order to ensure that the correct support is accessed to determine whether or not the case/incident warrants a referral and where appropriate, to ensure that the referral form includes all the relevant information/analysis. Where this is not possible, and/or consultation within the referring agency does not reach an agreeable outcome, referrers will be expected to contact the WSCB Manager in order to discuss any ongoing concerns.
PLEASE ENSURE THAT ALL THE RELEVANT INFORMATION IS REFLECTED WITHIN THE COMPLETED/SUBMITTED FORM. THE STAFF WITHIN THE MAST WILL USE THIS INFORMATION TO ASSESS RISK.
1. ContextI am completing this referral because: (please tick as appropriate):
I CONSIDER THIS CHILD IS AT RISK OF SIGNIFICANT HARM
I CONSIDER THIS CHILD IS IN NEED OR VULNERABLE
I CONSIDER THIS CHILD MAY BENEFIT FROM SUPPORT THROUGH AN EARLY HELP ASSESSMENT
I CONSIDER THIS CHILD MAY BE VULNERABLE TO CHILD SEXUAL EXPLOITATION – Support the concern by completing CSE Risk Assessment
I CONSIDER THIS CHILD MAY BE VULNERABLE DUE TO DOMESTIC ABUSE
I CONSIDER THIS CHILD TO BE A YOUNG CARER
2. Referrers Details
This is (your name):
I am a (job title):
from (organisation):
Postal address:
Email address: / Telephone Number: (including mobile)
My relationship to the child concerned is:
Early Help Assessment
§ The Early Help process has/has not been followed (Delete as appropriate)
§ If the Early Help process has been followed when was it completed
(date)?
Please attach a copy of the latest assessment and reviews, go to Section 4.
§ If it has not been followed, please outline why and complete the following sections;
3. Child/Young Person’s Details
Name of the child / young person:
/Known as / Aliases:
Surname: / Forename/s:DOB (or expected date of delivery):
/ /Gender
/Male
Female
Unborn
Home Address (Inc. postcode):
/Tel No (including mobile numbers):
/Any other known addresses (Inc. postcode):
/4. Child / Young Person’s ethnicity and language: Please tick the relevant box or populate the relevant cell
A. White
/ British / Irish / Polish / Any other White Background:B. Asian or Asian British
/Indian
/Pakistani
/Bangladeshi
/Any other Asian Background:
C. Black
/Caribbean
/African
/ /Any other Black Background:
D. Dual Heritage
/White and Black Caribbean
/White and African
/White and Asian
/Any other dual heritage Background:
E. Chinese/other ethnic background
/Chinese
/Gypsy
/Romanian
/Any other ethnic Background:
F. Any other ethnic group: Please specify
G. Information not yet obtained:
/ /H. Information refused:
/ /Child / young person’s first language and/or preferred method of communication e.g. sign language:
/Parent / carer’s first language:
/Does the child / young person have a disability? Please give details
/Is an interpreter / signer required? YES/NO/PLEASE SPECIFY
5. Additional Information:
Is the child / or has the child / young person been the subject of a child protection plan? YES/NO
/If yes, please state in which local authority and provide further details if known:
Is the child or has the child / young person been a looked after child? YES/NO
/If yes, please state in which local authority and provide further details if known:
6. Details of Child/Young Person’s Principal CarersName: / D.O.B:
Relationship to child/young person: / Do they have Parental Responsibility (PR)? YES/NO/DON’T KNOW
Address:
Postcode: / Telephone:
Name: / D.O.B:
Relationship to child/young person: / Do they have Parental Responsibility (PR)? YES/NO/DON’T KNOW
Address: / Telephone:
7. Other people living in the child / young person’s household
Name (including any known aliases) / D.O.B / Gender / Relationship to child /
young person / Also Referred? Y / N / Is the person known to pose a risk to children?
8. Significant others who are not members of child / young person’s household
Name / D.O.B / Gender / Relationship to child /
young person / Current Address / Tel. No.
9. Key Agencies (please provide the information below)
Agency / Name / Tel. No./Contact details
G.P
Midwife
Health Visitor
School Nurse
Children’s Centre
Nursery
School
School Nurse
Education Welfare Officer
Youth Offending Service
Police
Probation Service
Paediatrician
CAMHS
Other (please state)
10. Reason for Referral
(Please include as much information as possible. Remember that the assessment of the level of intervention required will be based upon the information that you provide. You will need to consider the child’s developmental needs; parenting and / or carer capacity to meet the child’s needs; and family and environmental factors).
Tick the appropriate statement and provide further details belowI have assessed the child personally and the specific concerns are…
I am concerned for the child’s safety / wellbeing because…
I have not been able to assess the child but I am concerned because…
(Provide specific facts – what you have seen, heard and/or been told and when you last saw the child and parents)
There has been a change since I last saw the child on (date):
The child is now (describe current conditions and whereabouts):
I have taken the following actions to make the child safe:
What has the child told you about how they feel?
Family Factors:
Specific family factors making this child at risk of significant harm are as follows: (please include any information with regard to the incidence of substance misuse, domestic abuse, parental mental health, learning difficulties or any other factors and how they impact on parenting)
Additional factors creating vulnerability are:
The strengths in the family situation are:
There might be risks to staff visiting the child’s family, they are:
Expected response:
In line with Working Together to Safeguard Children 2015 , NICE guidance and the Children Act 1989, I recommend that the following action is taken:
An urgent assessment as a child in need of protection.
For further assessment as a child in need.
For further support under Early Help Assessment/team around the child process
For information sharing purposes.
What services do you think will make things better / safer for the child?
What services will you continue to provide for the child?
Details of who you spoke to with the time and date:
11. Authorisation
Have you discussed this referral with your line manager? YES/NO Please include date and summary of the discussion/s:
Details of Manager/Supervisor:
Name: / Designation:
Tel no. / E-mail
Referrer’s Signature: / Date:
Are the parent (s)/guardian (s) aware of the referral? YES/NO, If no please give reason/s / Is child/young person aware of referral? YES/NO If no please give reason/s
Have the parent(s)/guardian(s) given consent for the referral to be made? YES/NO
If the answer to either of the above is NO please provide an explanation. It is essential that professionals work in partnership with families and talk with them about their concerns, unless to do would place a child or family at immediate risk
Have parent(s)/ guardian(s) been advised that support may be offered from Early Help? YES/ NO / If parent (s)/guardian(s) have advised of the Early Help offer, have they consented to this? YES/ NO
Is any information contained in this referral to remain confidential from the child and family?
If so, please outline specific information to remain confidential and the reasons.
NB details of referrer - if a professional person, cannot be held as confidential apart from in exceptional circumstances.
12. Consent
If you are making a Child in Need (CIN) Referral, agreement must be sought from the parent/carers (and where appropriate the Young Person). If parental agreement is not and/or cannot be obtained, it will not be possible to progress a Child in Need Referral. Wherever possible, the parent/carer should be asked to sign this referral form.If you are making are making a referral due to a Child Protection concern and are unsure about whether to advise the parent/carer about the referral – please ensure that you consult with your agency.
Parental/guardian Consent:
I agree to the information held within this referral form to be shared with Children’s Services.
Name of Parent/s/Legal Guardian:
Signature/s of parent/s/Legal Guardian/s:
Date:
*Please note that any information sharing needs to be in accordance with your agency’s information governance processes and Working Together 2013. If you are unsure please check with your agency’s
Designated Safeguarding Lead or the Walsall Safeguarding Board Manager.
13. Once you have completed this form please return this form in a secure manner to:
The Multi Agency Screening Team (MAST)
Fax Number: 01922 658195
Email address:
14. If you require this form in any other format or language, please contact Walsall Safeguarding Children Board (WSCB) using the contact details below:
Walsall SafeguardingChildren Board (WSCB)
The Walsall Council House
Lichfield Street
Walsall
WS1 1TW
TEL: 01922 652559
www.wlscb.org.uk
Walsall Child Protection Procedures: www.wlscb.org.uk/wscbindex/wscbprotection.htm
Reviewed: APRIL 2015