Flying Start Children S Centre Referral Form
Flying Start Children’s Centre Referral Form
Main Parent/Carer Details(Person with parental responsibility) / Parent/Carer Details
(Person with parental responsibility)
Name: / Date of Birth: / Name: / Date of Birth:
Address Details (Number, Street, Town, Postcode) / Address Details (Number, Street, Town, Postcode)
Preferred Contact Phone Number / Preferred Contact Phone Number
Children (living at same address)
Name: / Date of Birth: / NHS Number:
Name: / Date of Birth: / NHS Number:
Name: / Date of Birth: / NHS Number:
Referrers details
Name: / Job Title/Agency:
E-Mail: / Tel:
Are there/were there other agencies involved? / No / Yes (Please list below)
Name: / Job Title & Agency: / Contact Details: / Currently Involved?
Needs (please tick relevant needs)
Child/ren / Parents/Carers / Family/Environmental
Weight/Feeding/Eating Problems / ☐ / Mental ill-health (P4) / ☐ / Housing/overcrowding (P2) / ☐ /
Physical/Mental disability (S2) / ☐ / Substance/Alcohol misuse (P9) / ☐ / Family breakdown / ☐ /
Poor health/disorder / ☐ / Social isolation (S11, S12) / ☐ / Financial stress (P6, P7) / ☐ /
Dental / ☐ / Current/historic offending (S8) / ☐ / Worklessness (P1) / ☐ /
Sleep routines / ☐ / Young parent / ☐ / Domestic violence (P8) / ☐ /
Special Educational Needs (SEN) (S2) / ☐ / Disability/Illness (P5) / ☐ / Adult Learning (P3, P7) / ☐ /
Challenging behaviour (S2, S7) / ☐ / Lone parent / ☐ / Large Family (S3) / ☐ /
2 Year funding / ☐ / Routine/daily living needs (S2, S7) / ☐ / Safe at Home / ☐ /
Low self-esteem / ☐ / Behaviour management of child / ☐ /
Child development concerns (S2) / ☐ / Language barriers / ☐ /
Speech & Language difficulties / ☐ / Lifestyle impacting on child / ☐ /
Toileting / ☐ / Immigration (S13) / ☐ /
EY/Educational Attendance (S1, S4) / ☐ / Parenting Course
…………………………………………………… / ☐ /
Development check DNA / ☐ /
Consent & data protection agreement (professionals referring into Flying Start)
Have the individual/s given permission to share their information with other agencies? / Yes / No
In what form was the consent given? / Written / Verbal
Referrers Signature: / Date:
Consent & data protection (parents)
Flying Start is committed to protecting your privacy. We will process the information you provide in a manner that is compliant with the Data Protection Act. The Flying Start privacy statement can be viewed on
I consent to my information being shared with Flying Start
Signature / Date
Current Concerns: Does the baby or child appear to be…
Healthy?(Consider the presentation i.e unkempt, malnourished, layering of clothing. Any health issues, dental, odour, attending appointments)
Safe from harm?(Consider change in behaviour, groups being accessed, relationships, family dynamics, friendships, radicalisation, exploitation, anti-social behaviour, criminal activity)
Learning and developing?(Consider attendance levels, engagement, progress, milestones, journey to school, transition, agencies involved, bullying)
Having a positive impact on others?(Consider role models, relationships, dynamics, attachment, friendships, historical relationships)
Free from the negative impact of poverty?(Consider financial situation historical and present, accessing funding, pupil premium, previous care status, economic)
Having historic or complicating factors? (What factors contribute to the difficulty for the child/ren & family)
Grey Areas: (Areas of uncertainty which require further exploration) / What interventions have been tried or are in place? (i.e. EHA, Graded Care Profile, Social Care Referral, MARAC, Parenting Programme etc)
Support required from Children’s Centre:
v. Feb 17Flying Start Children’s Centre Referral FormP.T.O