ACTION FOR CHILDREN SERVICE REQUEST REFERRAL FORM
TOGETHER FOR FAMILIES
FAMILY INTERVENTION PROJECT (FIP)
§ Please feel free to discuss any potential service requests with the Project:
Action for Children, Helford House, May Court, Truro Business Park, Threemilestone, Truro, TR4 9LD
Tel: 01872 321486
Fax: 01726 341100
Email:
Name of young person/ family:Date of birth: / TF Number :
Disabled Child/Young Person
YES NO / Type of disability:
Ethnicity: / Gender: M / F
Parent Details:
Mother: ………………………………. DoB: ..…/.…../…... Parental Responsibilty? YES NO
Father: ………………………………. DoB: ..…/.…../…... Parental Responsibilty? YES NO
Siblings:
Name: ………………………….. DoB: ……/…../….. Name: ………………………….. DoB: ……/…../…..
Name: ………………………….. DoB: ……/…../….. Name: ………………………….. DoB: ……/…../…..
Name: ………………………….. DoB: ……/…../….. Name: ………………………….. DoB: ……/…../…..
Name: ………………………….. DoB: ……/…../….. Name: ………………………….. DoB: ……/…../…..
Family Address:
Telephone No:
The following documents MUST be included with this referral if carried out within the last 6 months – indicate with a tick which documents you will attaching with this referral.
Early Help Assessment, Plan and review
CAF, TAC minutes and action plan Most Recent Assessment Child Plan Genogram Current Plan of Support
Referrer Information
Name
Address
Telephone / Mobile No
Email address
Signature
Date
Which statutory, non statutory or voluntary sector organisation are you part of? Please detail which team/department if applicable? / Referral & Assessment (RAS)
ChiN
Children’s Specialist Social Work Service
Child Protection and Children in Care Team
Localities(please state which Locality and role)
TF Advocate EWO Police ASB
Addaction
Other ……………………………………...…………(please specify)
TOGETHER FOR FAMILIES (see Together for Families Sheet for details)
TF Number (if known) ………….
Please tick relevant boxes below:
1. Educated at a Short Stay School or by alternative provision because of exclusion OR
persistently absent from school OR has received 3 fixed term exclusions
Source of this information: ……………………………………..
2. In the last 12 months, either a young person has entered the criminal justice system, or any member of the family has anti-social behaviour that has come to the attention of the ASB team or landlord
Source of this information: ……………………………………..
3. Any member of the household is dependent on a workless benefit
Source of this information: ……………………………………..
Where only 2 of the Together for Families criteria above are met, 1 of the following criteria must also apply:
Child development and welfare affected by domestic violence
Parenting undermined by alcohol/substance misuse
Parenting undermined by mental health problems
Housing issues, including risk of eviction
2/3 year old funding – non-take up
Please identify what assessments and plans are currently in place and for which member of the household and attach copies.
Plans in place / Name:
………… / Name:
………… / Name:
………… / Name:
………… / Name:
…………
CAF/TAC
Child Protection Plan
Child Plan (CIC)
Children in Need Plan
Early Help Plan
Statutory Education Order
ASB (e.g. ASBO or ABC)
Other: please specify
Additional Information:-
e.g. Are you aware of any danger associated with home visits? If yes, please give details. For example, dangerous dogs, syringes, violent family/visitors, adult family members with restricted access to the family, or is there anything else we need to know?
What additional services or support do you think would benefit this family and help them achieve their objectives?
What support do you think this family would benefit from?
What is the role you see for FIP?
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2.
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4.
5.
Family Signature(s)
I/we agree that the process has been explained to us. We would like to go ahead with this referral, and I/we agree to the information that I/we have given being shared by Action For Children with a number of different agencies such as Health, children’s trust, youth offending service, criminal justice, registered social landlords and the education, housing and social care services within Cornwall Council. This joint working will provide a coordinated Support Plan to meet our needs.We also understand that Action for Children will use our information to ensure that the services we receive are of continuing high quality.
We will treat your information throughout this process confidentially and limit access to it to only those who need to view it.Action for Children and Cornwall Council adheres to all the principles of the Data Protection Act 1998. Your information will be stored electronically on password protected and access controlled computer systems. Our Data Protection policy can be viewed at www.actionforchildren.org.uk and www.cornwall.gov.uk
I/We understand that Action for Children will retain data for a minimum of six years from the end of our use of these services, that this may include electronic data or paper records, and that as individuals we have the right to access our own data at any time during this period.
Information will be used to assess your family’s suitability for the Action for Children services.
Signed (Parent/Carer)
Date:
Signed (Young Person)
Date:
Please return together with the most recent assessment, CAF, chronology and genogram and any current plan of support to:-
Cornwall Family Intervention Project ● Helford House ● Truro Business Park ● Threemilestone ●Truro ● TR4 9LD
OR Email:
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