CSE Referral Form

This multi-agency form should be completed online before being submitted to the SPA CSE Lead via or

Schools can use secure email USO-FX

Secure emails:
Kingston:

Richmond:

The LSCB guidance includes tools to develop an understanding of risk indicators in order to complete this form (see appendices 2- 5).

Consent

Consent from the parents or child/ young person is not required to complete this form. Personal data and other information can be provided:

  • For the prevention and detection of crime or the apprehension or prosecution of offenders;
  • Where there are concerns of significant harm for a child.

(Data Protection Act 1998; London Child Protection Procedures 2015).

Name of Referrer: / Agency:
Role:
Date of Assessment: / Tel:
Date of referral to SPA: / Email:

While it may be appropriate to complete the checklist with the child/family of the child, consideration should be made of whether engaging the child and family and alerting them to the risks may compound risk or further alienate the child. Please note if this form was completed in consultation with:

The child / The child’s parent(s)
Definition of CSE
This guidance uses the nationally agreed ACPO definition of CSE:
  • Sexual exploitation of children and young people under 18 involves exploitative situations, contexts and relationships where the young person (or third person/s) receive ‘something’ (e.g., food, accommodation, drugs, alcohol, cigarettes, affection, gifts, money) as a result of them performing, and/or another or others performing on them, sexual activities.
  • Child sexual exploitation can occur through the use of technology without the child’s immediate recognition; for example being persuaded to post sexual images on the internet/mobile phones without immediate payment or gain.

If ‘other’ please specify in ‘actions to date’ below
Child / Person of interest[1](please see the bottom of the page for guidance on persons of interest)
Forename(s):
Surname:
Alias
Address 1: Family Address
Address 2: Current Address (if different)
Address 3:
Postcode:
Gender:
Sexual orientation:
DoB:
Language Spoken:
Ethnicity:
Disability:
Lead Practitioner:
Social Worker: / Person of interest description
GP:
Other professionals:
School:
Known to CSCsince:
Locations of interest[2](e.g. Youth Clubs, Parks, Taxi Ranks, Food Outlets):
Additional details: i.e.: Vehicle Reg/details Oyster Card details /other intelligence
‘Gang’ or ‘group’ affiliation:
Relationship of person of interest to subject (e.g. boyfriend, pimp, associate):
Summary of concerns:
Actions to date:
Further details of agencies involved with either party:
Consent to share info Y/N:
CSE Warning Signs - complete relevant sections with reference to guidance ( CSE Risk Matrix or Brook Child Sexual Exploitation Proforma):
S - Sexual health and behaviour
A - Absent from school or repeatedly running away
F - Familial abuse and/or problems at home
E - Emotional and physical condition
G - Gangs, older age groups and involvement in crime
U - Use of technology and sexual bullying
A - Alcohol and drug misuse
R - Receipt of unexplained gifts or money
D - Distrust of authority figures
Details of CSE Concerns:
Actions:
(please record actions taken to date)

[1]A person of interest is someone who appears to be developing afriendship or relationship based on power over a child by virtue of their age, gender, intellect, physical strength and/or economic or other resources

2If there are specific locations where a vulnerable child is spending time, please note it here.