-CONFIDENTIAL-

REFERRAL FORM

PARENT ONE / M / F / PARENT TWO / M / F
Name of Main Carer
Date of Birth
Address
Can parent two be contacted?
Yes No
Tel (Mobile & Landline)
& Email
Name of last school parents attended
First Language / Does the family need an interpreter? YES/ NO
Schools Children Attending
Details of all other members of household (please give as much information as possible)
Child or Adult / Surname / First Name / DOB / M/F / Relationship to main carer
This Referral is made by :
NAME / ORGANISATION
ADDRESS / TELEPHONE
DATE REFERRAL
MADE / EMAIL
DETAILS OF ANY RISKS TO WORKING WITH THE FAMILY
e.g. violence,drugs,pets,syringes
DETAILS OF ANY PROFESSIONALS CURRENTLY WORKING WITH THE FAMILY
Is this referral for; (PLEASE TICK ONE ONLY)
Parents Moving Forward course
(FMF key worker facilitated parenting course based on NVR principles)
Including access to Monthly graduate parent group
PERMISSION GIVEN TO CONTACT PROFESSIONALS INVOLVED
YES / NO
MAIN CARER SIGNATURE OF CONSENT FOR REFERRAL
……………………………………………………………………. DATE ……………………….
Has there ever been any Social Care intervention ? / YES / NO
If so when & who was the Professional Lead?
Has a SAF been completed ? YES / NO If yes please attach
Lead Professional
Date of next TAC/TAF Professional meeting
MAIN REASON FOR REFERRAL

-CONFIDENTIAL-

FAMILIES MOVING FORWARD ELIGIBILITY CHECKLIST

NAME OF MAIN CARER:

FAMILIES MOVING FORWARD ELIGIBILITY CRITERIA
If you have ticked YES to statements 1-2 and ticked at least one in section 3 and one in section 4 please complete our referral form at the back of this page. / YES
1 / Is the target child in the family in Academic year 5, 6 or secondary education?
2 / Is the family living in Portsmouth and/or the eldest child attending school in Portsmouth?
3 / The family have experienced the following:
You must be able to tick at least one of the following:
a / Child Displaying behavioral problems which make them or others vulnerable to harm or to statutory/criminal justice intervention
b / Bullying or controlling behavior within family relationships
4 / The family can be described as:
You must be able to tick at least one of the following:
a / Parents require support with parenting
b / Disability, long-term health problem, or special educational needs
c / Poor school attendance
d / Suffering with Mental Health (including depression, stress, anxiety, isolation etc)
e / Single parent, recently separated families, or struggling with their relationship
f / Indicating drug and alcohol abuse
g / Indicating domestic abuse

Please return this form securely to: Email:

Families Moving Forward, Tel: 023 9229 6460

Unit 3, St George’s Business Centre Fax: 023 9229 3477

St George’s Square, Portsmouth, PO1 3EY

Privacy and Data Protection Policy

By consenting to this referral you consent to share the information you provide on this form with Families Moving Forward (Learning Links) and the Big Lottery families and consent to us undertaking work with children as outlined by the family action plan , which may involve seeing children in school. Your personal details will be safely kept in line with the UK Legislation on Data Protection. We will not keep your records for longer than needed. Please be assured that we do not sell or share any information about individuals with other organisations without your permission

Updated Nov 2013 (version 1.9) Registered Charity No. 1082908