Details of the Person Making This Referral

Referral

Details of the person making this referral

Name
Role
Organisation
Contact details
Date of Referral
Address (including postcode):
Telephone numbers and email:
Are you registered at the Childrens Centre? / Yes No

Household information

Please include all adults and children living in the household

Full Name / DOB/EDD / M/F / Relationship within family / Ethnic Origin

Other Significant People - include parents/carers not living in the family home

Full Name / D.O.B / Gender / Relationship to Child / Contact Details

Are there any risks in relation to home visiting or lone working?

Are there any identified barriers to accessing our service? (E.g. cultural sensitivities, physical access)

Please give details….. Yes No

Please tell us about the reason for the referral, how the Children’s Centre may be able to support or provide hardship funding*, and what outcomes you would like to achieve: (please contact the Childrens Centre if you require more information on the support available)

What is going well? / What are we worried about? / What support are you requesting from the Children’s Centre?
View of Parent/Carer
View of Child
View of Referrer
*If your request is for Hardship funding, please provide details of any means tested benefits income. The Children’s Centre are not able to provide long term funding. To increase the likelihood of the application being approved, please can you detail how the family may be able to work towards providing money towards or, to fully cover the cost of the funding request in the longer term. Please include the total amount of funding being requested within the application.

Details of Professionals currently supporting the family

Worker Name / Supporting Who / Role/Team/Agency / Contact details
Is the family currently engaged in an: FSP CIN Plan CP Plan
If yes, please identify the Lead professional’s contact details.

If this referral is accepted then a Children’s Centre practitioner will visit you to talk about our services and the support we can offer you and answer any questions you might have.

Declaration

I / We have read and agree to this referral to Corpusty/Holt, Stibbard & Wells Children’s Centres.

I / We agree to the information contained within this referral being shared with and stored securely by Action for Children, in accordance with the Data Protection Act 1998, for the purposes of identifying and providing support/funding to my family.

Please note that by giving this consent you are agreeing to the Children’s Centre discussing your family and circumstances, with the other professionals involved, to gather information. This helps us to provide the best support possible.

As a rule, the information that you provide will only be shared with yours and your child’s consent. The only times we will share information without your consent are:

· If we need to find out urgently if a child is at risk of harm or we need to help a child who is at risk of harm.

· If we need to help an adult who is at risk of harm

· If we need to help prevent or detect a serious crime

Name / Consent signature / Date
(Parent/Carer) / ……………………………………………….. / ……………
(Parent/Carer) / ……………………………………………….. / ……………
(Professional/Referrer) / ……………………………………………….. / ……………

This form must be signed by at least one Parent/Carer and the referrer to be accepted for support or funding. All unsigned forms will be returned to the referrer.

Please return this form to the Childrens Centre that the family are registered with:

Corpusty/Holt, Stibbard & Wells

Charles Road,

Holt

Norfolk

NR25 6DA

Or email, using a secure system, to Telephone: 01263 712442