This form should be used when a child or young person has oneclearly identified need which requires a response from one agency only.
IF YOU HAVE CONCERNS THAT A CHILD OR YOUNG PERSON IS AT RISK OF HARM
PLEASE CONTACT CUSTOMER SERVICE CENTRE WITHOUT DELAYON 0300 123 4043
PLEASE NOTE: ANY URGENT REFERRALS MADE AFTER 17:30OR AT THEWEEKEND MUST BE PHONED THROUGH TO 0300 123 4043

Please use Black ink when completing this form

Personal Details:
Name of baby, child or young person:
Forename(s): / Date of birth / EDD:
Surname: / Gender:
Names of Parent(s) or Carer(s): / Parent/Carer Contact Number(s):
Home Address: / Other household members and siblings:
(date of birth where known)
Child’s first language: / Immigration status:
Parent’s first language: / Translator/signer required? / YES / NO
White British / Caribbean / Indian / White & Black Caribbean / Chinese
White Irish / African / Pakistani / White & Black African / Any other ethnic group
Any other White background / Any other Black background / Bangladeshi / White & Asian / Not given
Gypsy/Roma / Traveller of Irish Heritage / Any other Asian background / Any other mixed background
Religion: / Asylum Seeker: / YES / NO
Reference No.: (please explain, e.g. NHS No., UPN etc):
Name of School/Early Years Setting & Contact person:
Name and contact details of GP:
Does the child/young person and or parent(s) carer(s) have a disability? If so, please detail: / YES / NO
Does the child/young person have any allergies? Is so, please detail: / YES / NO
Does the baby, child or young person appear to be:
Healthy?
Evidence/Comment:
Safe from harm?
Evidence/Comment:
Learning and developing?
Evidence/Comment:
(include frequency of school/nursery attendance)
Having a positive impact on others?
Evidence/Comment:
Free from economic difficulties (within the family)?
Evidence/Comment:
If you answered “No” to any of the above, what additional services are needed for the baby, child or young person or their parent(s), carer(s) or families?
Can you/your service provide the additional services needed? / YES / NO
If you are unable to provide additional services to address the need(s) there are two options:
  1. If you identify that the child/young person has a single need, continue completing this form to request a single support service. Follow the instructions for sending the form on the final page.
  1. If you identify more than one unmet/additional need,a Common Assessment Form (CAF), leading to a multi-agency team (Team Around the Family)response should be completed with the child/young person and or parent(s)/carer(s)
  1. The CAF Form and guidance will direct you further. The completed information above can form part of the CAF by way of an attachment.

THE FOLLOWING SECTION MUST BE COMPLETED IN ORDER TO REQUEST A SERVICE:

Please specify clearly the service to whom you are making a request:
Failure to complete this section will delay the process of accessing the correct service
What are the Desired Outcomes for the child/young person/family:
(Include expectation of service)

Please attach any further information that the receiving agency/service may need to know in order to respond.

SSR completed by:
(your full name and agency/service)
Contact details:
(in full – please include email address and contact number)
Date:
Consent
Parental consent is required to enable Information Sharing with the identified service. Young people should also be aware of the request for a service and asked for their consent. You will need to make a professional judgment about the young persons understanding of giving consent
  • I have had the reasons for this service request explained to me, I understand the reasons for the request and understand that my information will be shared with the identified service as part of this request.
  • I agree to the request and give consent for the named service to work with my child (or me as the named young person).
  • I give consent for the sharing of information to the above named service.
  • I give consent to the sharing of additional information attached to the above named service
  • I understand that the information contained in this form will be recorded on a Hertfordshire County Council case management system and others services may be able to see the content on this form.

Consent obtained? / YES/NO
If NO please give reason:

REMEMBER TO ASK CHILD/YOUNG PERSON AND OR PARENTS TO SIGN FORM.

Signed: Child/Young Person ………………………………………… Date …………………………
Signed: Parent/Carer ………………………………………………….. Date …………………………
Does the named child have an Early Support package in place? YES NO
If NO and you need the support of more than one service, please complete a CAF.
CDC Report Attached Yes No
CDC Report to Follow Yes No
Family aware that CDC/additional reports are to be shared with named service and have consented to them being attached to this form - Yes No

IF YOU HAVE CONCERNS THAT A CHILD OR YOUNG PERSON IS AT RISK OF HARM PLEASE CONTACT CUSTOMER SERVICE CENTRE WITH OUT DELAY ON 0300 123 4043

PLEASE NOTE: ANY URGENT REFERRALS MADE AFTER 17:30 OR AT THE WEEKEND MUST BE PHONED THROUGH TO 0300 123 4043

Confidentiality

This form contains personal family information.

Please ensure secure document storage and safe Information Sharing (See CAF Guidance)

SENDING THIS FORM

Requests for a single service from Children’s Services should be sent by post or email to the appropriate address in the table below. The team to which the request is being made should be specified clearly on page 3 of the form. Referrals for a single service from other agencies (e.g. NHS, CAMHS) should be sentdirectly to the appropriate address for that service.

Service / Area / District / Address / Email
Safeguarding and Child Protection
Disabled Children’s Services (Social Care)
Targeted Youth Support
Early Intervention & Targeted Support / Customer Service Centre
PO Box 153
Stevenage
SG1 2GH /
Integrated Services for Learning (ISL) Please identify on page 3which of the teams the request is for:
Access to Education for Refugees and Travellers, Behaviour and Attendance, Central Attendance and Employment Support, Communication Disorders, Early Years SEND, Educational Psychology, Education Support Centre (ESC), Education Support Team for Medical Absence (ESTMA), Sensory/Physical Needs
Please note that a parental signature must be included on all requests
North Herts and Stevenage / SFAR600
Farnham House
Six Hills Way
Stevenage
SG1 2FQ / NH&
East Herts and Broxbourne / CHN600
County Hall
Pegs Lane
Hertford
Hertford
SG13 8DQ / EH&
Welwyn/Hatfield and Hertsmere / County Hall (as above) /
St Albans and Dacorum / AP2600
Apsley Two
Brindley Way
Hemel Hempstead
Hertfordshire
HP3 9BF / STA&
Watford, 3 Rivers, Bushey and Radlett / Apsley (as above) / WAT&
Confidentiality
This form contains personal family information.
Please ensure secure document storage and safe Information Sharing (See CAF Guidance)

1

Name of child: Reference: October 2011

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