Request for Support from Early Intervention Service

Hubs, Children’s Centres & Thriving Families

Please note:for Children’sCentres this form can be used by the family to request support and there may not be a professional supporting them

Name of Children’s Centre/Hub:
(that this request will be sent to)
Date of Request:
Name of professional
supporting this request / Name of Agency / Agency Address / Tel No. / Email Address
Names of
children/young
people in family / Address / D.o.b. / Gender / Ethnicity / Name of School/
College/Employment
Status / In receipt
of benefits, if yes
which benefits / On a
Work Related
Programme if
yes which one

If this request is for a particular child/ren, which child/ren: ………………………………………….

Parent’s/Carer’s
Name: / Address / Contact
Tel. No. / D.o.b. / Ethnicity / Name of
College/
Employment
Status / In receipt
of benefits, if yes
which benefits
*(TF Criteria) / On a
Work Related
Programme if
yes which one
Parent’s/Carer’s
Name: / Address / Contact
Tel. No. / D.o.b. / Ethnicity / Name of College/
Employment
Status / In receipt
of benefits, if yes
which benefits
*(TF Criteria) / On a
Work Related
Programme if
yes which one

First Language spoken ……………………….

Is an interpreter required Yes/No

Pregnant: Yes/No If so, expected date of delivery …………………..

Any other important adults in your child/children’s life that may or may not live with you:

Name of adult / Relationship to children / Address / D.o.b.

If a professional is supporting this request please complete the following:

Has a CAF been completed for relevant child/young person/family: / Yes/No
Is there a TAC/TAF/TAYP in place: / Yes/No
Name of Lead Professional: / Agency: / Telephone Number:

Please give us an outline of why you are requesting a service from the Hub/Children’s Centre:

Background Information
We would like help and support with the following
Views of any other family member e.g child/young person

Please tick if any of the following are supporting your family

Professional/Agency / Name / Contact No: / Please tick to show
that you have given
permission for the
Hub/Children’s Centre
to contact
Midwife
Health Visitor
Homestart Volunteer
GP
School/Pre-school setting
Social Worker
Housing Support Officer
Drug/alcohol counsellor
CAMHS
PCAMHS
Youth Offending Service
Specialist NEET/
Youth Contract
Skills Training UK (STUK)
Police
Other

In signing this form you are agreeing for the Children’s Centre/Hub to contact you and for the information contained within to be held by the Children’s Centre/Hub. All information will be treated in the strictest confidence in accordance with the Data Protection Act. For the benefit of your children we may request and or share information with other professionals from Health or from other professional teams in the Children, Education and Families Directorate.

Signature of applicant / Date
Signature of professional supporting this request / Date

For request to Hub only:

If the professional supporting this request is unable to obtain the signature of parent/carer please confirm whether the child/young person/family is aware of and in agreement with this request:

Young person/family is in agreement:(tick here) □

The following checklists are to help you in filling in this request Areas of Support

Child/Young Person / (tick) / Parent / (tick)
= Thriving Families Criteria / = Thriving Families Criteria
School Attendance/Absenteeism / Offending behaviour/risk
In pupil referral unit or alternative provision because at risk of exclusion or previous exclusion (TF Criteria) / Families subject to frequent police call-outs or arrests (TF Criteria)
15% absence or more from school across the last 3 consecutive terms (TF Criteria) / Adults proven offences in last 12 months
(TF Criteria)
3 or more fixed school exclusions or internal isolation episodes across the last 3 consecutive terms (TF Criteria) / Parent or other family member in Prison
(TF Criteria)
Subject to or at risk of permanent exclusion (TF Criteria) / Parent with history of imprisonment
(TF Criteria)
Not on school roll (TF Criteria) / Prolific offender within families
(TF Criteria)
Academic under achievement / Involved in gang related crime
(TF Criteria)
Offending Behaviour / Health issues
Anti-Social Behaviour / Under 18 conception (TF Criteria)
Household with 1 or more under 18 with a proven offence in the last 12 months
(TF Criteria)
Youth Restorative disposal / Drug and alcohol misuse (TF Criteria);
  • Drugs
  • Alcohol

Households where 1 or more member has any informal or formal reprimand due to anti-social behaviour within the community or in relation to housing situation in the last 12 months (TF Criteria) / Long term health conditions
Parent has disability;
  • Physical
  • Learning

Involved in gang related crime (TF Criteria) / Domestic abuse (TF Criteria);
  • Current
  • Previous

Safeguarding concerns / Domestic abuse (TF Criteria);
  • Perpetrator
  • Victim

Child on Child Protection Plan (TF Criteria) / Parent unemployment/NEET
(TF Criteria)
Local Authority is considering accommodating as a looked after child (TF Criteria) / Education, employment and training
On CP Register previously / Accessing local services/social isolation
Attachment issues / Parenting challenges/difficulties
Support for development delay / Managing behaviour
Child has disabilities;
  • Learning
  • Physical
/ Breastfeeding support
Physical illness / Emotional support
Long term illness / Managing lifestyle changes
Sibling physical disability / Poor self-care
Young Carer
Child/Young Person / (tick)
Young parent to be;
  • Mother
  • Father

Young parent;
  • Mother
  • Father

Mental Health issues
Support for emotional wellbeing
Low self esteem
Housing issues;
  • Homelessness
  • Environmental issues

Living independently
Poor self-care
At risk of becoming looked after
Loss/Bereavement
Dietary issues
Social isolation
Neighbourhood conflict
Harassment;
  • Perpetrator
  • Victim

Discrimination;
  • Perpetrator
  • Victim

Substance misuse;
  • Alcohol
  • Drugs

Sexualised behaviour
Bullying;
  • Perpetrator
  • Victim

Domestic abuse victim
Refugee/Asylum seeker
Behaviour difficulties
Communication and/or interaction difficulties
Peer relationship difficulties
Please state any other information that the Early Intervention Staff
may need prior to visiting
Previous or current use of drugs/alcohol
Is anybody currently under police caution
Any current or previous child protection concerns
Are there any dangerous animals, including dogs in the household.
Is there currently, or has there been a history of domestic violence.
Is there currently or has there been a history of mental health issues
Any other adults living in the house e.g lodgers, friends/family staying, house share
Any other known risks to staff please specify

On completion of this form please forward to Children’s Centre or Hub of the

child’s home address to access support.

The Children’s Centre/Hub willcontact you to discuss the referral

If Thriving Family (TF) Criteria is met, Early Intervention Service to forward referral to:

1

Single Request for Support Form Feb2013