Appendix 2

CYPS Children’s Centre Early Intervention Team

Service Request Form

Request for service or support from Children’s Centre / Date: …
Common Assessment Completed? (Tick  box) / (Detail date below)
…………………
Name of referrer / Service / Contact Number/Address
Consent (1) – Identify who has consented / Child/young person / Parent/Carer
Name of child/ren
Young Person/s / D.O.B. / Address and contact number / Gender / School/Nursery
Home language / Disability (2) / Religion (2) / Ethnicity (2)
Family Composition: Identify adult/s with Parental Responsibility, and other significant family members e.g. grandparents. To prevent repetition you may write “refer to the CAF” if the information has been included and completed within the last 3 months
Name / D.O.B. / Relationship / Address/Tel No.
Reason for request. Ensure the reason for the request is clearly explained and that the evidence for the concerns is stated, distinguish fact and opinion. Include any Health and Safety issue. To avoid repetition you may write “refer to the CAF” if it has been included and completed within the last 3 months
Support requested / What will be the impact of this for the family and why is it needed now?
Other professional’s known to have current or past involvement with the family. (Please star if involvement is current) To avoid repetition you may write “refer to the CAF” if the information has been included and completed within the last 3 months.
Agency / Name / Address/contact details
Name of Lead Professional (if one in place) / Address/contact details

Signed by young person/parent/carer

Level on Continuum of Need at time of request

Signed by Manager / Senior CC EI Worker

Outcome of Service Request (To be filled in by Manager):

Please return to:

NOTE (1): Consent to record personal client information:

It is imperative that the Council has on record the appropriate consent to record or share client information.

It is the responsibility of the person who is appointed to manage this request to:

  • confirm that the client is fully aware of the Council’s Data Protection Policy (details available on the Council website at
  • confirm that the client has given the appropriate consent and that this has been recorded in line with Council policy.

NOTE (2): Equality Monitoring:

It is the responsibility of the person who is appointed to manage this request to ensure that the client has completed an ‘Equality Monitoring Form’ in line with Council policy.

Issue date: June 2011

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