FSOW1

Request for Children’s Centre Support

Request information (please complete this form with the parent/carer)

Family details

Date received at centre:
Family address:
Postcode:
Contact tel. no.: / Mobile:
Email:
Family doctor: / Tel No:
Health visitor: / Tel No:

Parent/carer (please record details of those present or from whom consent has been received)

Full name / Date of birth / Relationship to child
Full name / Date of birth or EDD unborn baby / M / F / School/pre-school/ nursery attended

Children (please include all children within the household and details of any pregnancy)

Other people living in the family home

Full name / Relationship to parent/carer

Referrer details

Name:
Role:
Organisation:
Email: / Address:
Postcode:
Tel. no:

CC use only

Estart number: / Forwarded to another organisation / Yes / No
Forwarded to:

Other agencies currently involved with the family

(Please tick and add names and numbers when known)

Family doctor
Health visitor / Midwives
Children’s Social care / NHS Speech and Language Therapy
Home-start / Paediatrician
Nursery/Pre-school / Portage
Domestic Abuse services / Troubled Families Worker
Adult mental health/drug/alcohol services / Voluntary Organisation
CAMHS / Other

What support has the family already been offered?

Include details of assessments relating to this request for support that have been carried out, and include the documentation with this form.

What are the issues and how can we help?

Are there any current/previous safety issues that the outreach staff must be aware of? (e.g. domestic abuse, alcohol/substance misuse, dangerous pets in family home)

Support requested

Any family with a child aged under 5 years who lives in Hampshire and has been identified as in need of additional support is eligible. When discussing the type of support required with the parent(s)/carer(s), practitioner’s should ensure that the needs of the child are at the forefront.

Please tick the relevant areas below relating to this request for support.

Children’s Centre Support

Linking with parenting programmes - links to services that improve children’s sleep, toileting and introducing/maintaining routines.

Managing the household - modelling good organisational skills, budgeting and signposting. Support with housing and financial issues, for example linking with debt counselling services and Jobcentre Plus.

Supporting healthy lifestyles - support with child safety, family nutrition and exercise, planning family meals, linking with oral health.

Managing behaviour of children - working with families to assess needs, and support positive parent/child interaction, as well as reduce parental conflict.

Raising confidence and self esteem - increasing emotional and physical wellbeing of parents and children.

Opportunities for play - offering play within the home and support to access play activities in the community to reduce isolation.

Support for children presenting with, or at risk of, delayed language and communication.

To be completed only if requesting support for delayed language and communication.
Name of child/ren requiring support:
1………………………………………… 2……………………………………………….
Type of difficulty (please tick)
Understanding instructions or questions. / Using a wide range of words.
Attention and listening / Joining words together.
Social interaction / Speaking clearly
(e.g. says “dar” instead of car.)
Summary of concerns:

Consent signatures: please sign overleaf

Consent signatures

I declare that all information I have provided is true to my knowledge. By registering these details I understand that the information will be held confidentially on the Hampshire Children’s Centres database and only shared with partner organisations such as Hampshire County Council Services, health services, and children’s agencies, for the purpose of contacting families to provide appropriate and timely services, evaluate service provision and for statistical analysis.

Under the Data Protection Act 1998, any confidential information regarding your family will not be passed onto organisations outside of Children's Services partners, as mentioned above, without your consent, unless it is of a Child Protection nature, in which case information will be shared with appropriate agencies. Registration data may be shared with neighbouring authorities if you live outside of Hampshire County Council boundaries to ensure you receive appropriate services.

I have read and understood the above and give my consent for Hampshire’s Children’s Centres to store the information in this form and any further information provided.

Signed (parent)………………………………………..…………………………

Signed (person making request)……………………………………………….

Role………………………………………………………………………

Please send completed form to your local children’s centre.

Details can be found at http://www.hants.gov.uk/childrens-services/childrenandyoungpeople/childrens-centres/childrens-centres-search.htm

CC Request for Support Form. Version 4. Page 1 of 4