Referred Child details
Name / Date of Birth / Gender M/F / Level CIC/CP/CIN/EHA / Ethnicity
 CIC  CP  CIN EHA
 CIC  CP  CIN EHA
Siblings/other children in family home
Name / Date of Birth / Gender M/F / Level CIC/CP/CIN/EHA / Ethnicity
 CIC  CP  CIN EHA
 CIC  CP  CIN EHA
 CIC  CP  CIN EHA
Parent/carer details
Name & Relationship / Phone / Date of Birth / Email / Address & Postcode / Ethnicity
Other adults living in family home
Name & Relationship / Phone / Date of Birth / Email / Address & Postcode / Ethnicity
Preferred method of contactIncluding any communication needs
 Telephone  Email  Letter  Other ………………..
What are the needs of the referred child? I.e. 0- 8 years
What would you like to see changed for the referred child? TO BE COMPLETED BY THE FAMILY
For the referrer: please indicate which criteria you feel the family meet on the attached list.
Referrers contact details
Name:
Address: / Contact telephone:
Email: / Organisation:
Date of referral:
Please provide us with any information you feel is relevant for a Home Visiting Risk Assessment
Do the family have a dog?(please circle) Yes No
Criteria:
Please select all of the criteria which you feel is met for the parent/carer. Please see all that apply
Historical childhood abuse / Adult disability/learning difficulty
Domestic abuse, current or previous / Child disability/developmental delay
Substance misuse current or previous / Neglect
Mental illness or distress in household / Sexual abuse
A parent in prison or custody / Emotional abuse
Care leaver / Asylum seeker/refuge
Conflict in parental relationship / Child in Care/Child Protection/Child in Need
Homelessness/risk of eviction/insecure housing / Early Help Assessment
Workless household/poverty / DHViP
Cultural and language barriers
If you are unsure about which of the above to select then please do contact the Children’s Centres using the contact details contained on the referral form.

Please e-mail to or post to North Devon Children’s Centres, The Hub, Sticklepath Children’s Centre, Woodville, Barnstaple, EX31 2HH

or for Torridge, please email or post to Bideford Bay Children’s Centre, Victoria Park, Bideford. EX39 2QQ

Staff use only
Allocated to: / Date: / E:aspire Nos / E:start nos: