Firesetterintervention Ormalicious Calls Referral Form

PROTECT - PERSONAL

FM/7/1/1/9

Page 1 of 3

(SB09/11)

FIRESETTERINTERVENTION ORMALICIOUS CALLS REFERRAL FORM

PROTECT - PERSONAL when complete email only to

This Referral Form generated by:

Child/Young Person (YP) andParent/Guardian/Responsible Adultdetails

Name of Child/YP: / DOB:
dd/mm/yyyy
AKA of Child/YP (if applicable)
Gender: / Not KnownMaleFemaleNot SpecifiedMALE / Age:
Ethnicity: / Not KnownWhite-English/Welsh/Scottish/Northern Irish/BritisWhite IrishWhite Gypsy or Irish TravellerWhite-Any Other White BackgroundMixed-White or Black CaribbeanMixed-Multiple/Ethnic GroupsWhite & Black CaribbeanWhite & AsianAsian or Asian British-IndianAny Other Mixed/Multiple Ethnic BackgroundAsian/Asian BritishIndianPakistaniBangladeshiChineseAnt Other Asian BackgroundBlack/African/Caribbean/Black BritishAfricanCaribbeanAnt Other Black/African/Caribbean BackgroundArabAny Other Ethnic GroupW/B
Address of Child/YP:
Please provide Post Code for the address.
Name of Parent/Guardian/Responsible Adult: / SARAH GARROT
Relationship to Child/YP: / Not KnownBiological MotherBiological FatherBiological ParentsBiological Mother/Step FatherBiological Father/Step MotherGrandparentFoster CarerCare of Local AuthorityOther Family Member
Home Telephone:
Mobile Telephone Number:
Email Address (If Applicable):
Is Parent/Guardian/Responsible Adult aware of this referral and consents to Hampshire Fire and Rescue Service (HFRS) contacting them? / Not RequiredYesNo
Does the Child/YP have any disabilities (e.g. ADHD, Autism, hearing problems, learning disabilities or behavioural problems)? Diagnosed or Undiagnosed / Not KnownYes DiagnosedYes UndiagnosedNo / If Yes Description
Is the Child/YP on any medication (could affect the time of visit): If so please list and state if taken AM/PM / Not KnownYes AMYes PMYes AM & PMNo / If Yes Description
Name of School:
School Contact Name if known
School Year & Key Stage / Year / Key Stage
Is Child/YP Excluded from school?

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Continued

How many Children/YP reside in the property and their ages? / Not Known12345678 / Ages
Number of adults residing within the property: / Not known1234562
Are there any pets? What and how many? / Not KnownYesNo / If Yes what
Are there any other agencies working with the family? / Not KnownYesNo
If Yes please state who?
(Children and Families Services, Youth Offending Team, Child Adolescent Mental Health Service etc) / Children and Families Services
Name and contact details of any other professionals working with the family? E.g. Social Worker, Family Worker etc and contact number (if known) / Name / Contact
No:
Are there any smokers residing within the property? / Not KnownYesNo
Are there any smoke detectors fitted within the property? How many? / Not KnownYesNo / If Yes Number / Not known123456789
Type of Property? Semi Detached, Terraced etc, Please state if Privately owned, rented etc: / Not knownHouse DetachedHouse Semi DetachedHouse End TerracedHouse Mid TerracedHouse Flat/AppartmentHigh Rise Flat/AppartmentMaisonetteCottageBungalow DetachedBungalow Semi DetachedBungalow Terraced / Not knownPrivately OwnedPrivate RentedCouncil OwnedHousing Association OwnedShelted AccomodationResidential Home
Would the Parent/Guardian/Responsible Adult like HFRS to arrange a Home Fire Safety Visit? / Not KnownYesNo

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(SB09/11)

Child/YP Firesetting details

Firesetting Category? e.g. Fire Play, Arson, Firesetting, Malicious Calls / Not KnownFiresettingFire PlayArsonMalicious Calls
Any previous Firesetting behaviour: (If known) / Not KnownYesNoyes
Source of Ignition: e.g. Lighter, matches, candles etc / Not KnownLighterMatchesLighter & MatchesCookerCandel IgnighterCandlesCombination of Combustable Materials
Location/Place of fire: e.g. Own bedroom, internal bin, external area etc / Not KnownOwn BedroomOther BedroomElsewhere in HomeOther HomeGardenExternal AreaSchool Premises ExternalSchool Premises InternalVarious Locations
Motivation: e.g. Excitement, fascination, attention seeking, peer pressure etc / Not KnownAttention SeekingAnger/RevengeExcitementBoredomCuriosityFacinationObsessionMental Health IssuesPeer Group PressurePeer Group InvolvementSelf HarmingVarious reasons
Details of Firesetting activities: Explain if possible what was used to light fire, e.g. matches, lighter or both and where e.g. own bedroom, external area etc, when and what was their motive e.g. boredom, peer pressure, fascination etc, also if others were involved.

Details of referrer

Name of Referee:
Relationship to Child/YP or Post Title:
Agency details and address with post code:
(ifapplicable):
Work contact number:
Mobilecontactnumber:
Email address (if applicable):
Is a copy of the parental acceptance letter required? / Not RequiredYesNo
Address letter to be sent if different to above address?

Hampshire Fire and Rescue Service supports the objectives of the Data Protection Act 1998 and is registered as a data controller. Information which you provide will be governed by the requirements of the Data Protection Act 1998 and may be processed by the Service in the performance of its statutory duties or for purposes required by law. More information is available at