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Family Support Service
Request for involvement
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Please use this form to refer to the following services:
  • Children’s Centers
  • Family Support Workers
  • Intensive Family Support
  • One-to-one Youth Service intervention including Drug & Alcohol Team and ‘Step In’

PLEASE COMPLETE FORM IN BLOCK CAPITALS. ALL SECTIONS MUST BE COMPLETED
Please send completed & signed form to:
Senior Administration Team
Prevention, Family Support and Youth Division
Families and Wellbeing Directorate
2nd Floor
New Town House
Buttermarket Street
Warrington
WA1 2NH


Telephone: 01925 442980 /

FOR OFFICE USE ONLY

Date form received:

Date entered into spreadsheet:

Date background search requested:

Date background search received:

Date of Allocation Meeting:

REFERRING AGENCY DETAILS

Name/Role/Agency:
Address:
Telephone number:
Email address:
Is this referral for an individual child / young person / adult or for the whole family? (please tick as appropriate)
Individual / / / Please complete all sections. / Family / Please go to section B.
If you have already completed an assessment on this individual / family, please attach with this referral

Please note, if at any time you feel that a child or young person has been harmed or abused,

or is at risk of harm or abuse, you must follow your local safeguarding children board (LSCB) procedures immediately.

What is the Family Support Service?
The Family Support Service is part of Warrington Borough Council’s Children and Young People’s Service. It includes teams of family support workers and youth staff who are able to work with individuals and their families to offer support at difficult times.
The Family Support Service aims to keep you informed at each step of your support. It is important that if you are referred to the service, you have agreed to and consent to the referral. If you change your mind, you can withdraw consent at any time.
Information from this referral will be kept securely on computer and in paper files, following procedures set out in the Data Protection Act 1998. This Act tells us what information can be held, how we must keep it safe and what access you have to it.
Section A

INDIVIDUAL CHILD / YOUNG PERSON / ADULT DETAILS

Name / Date of Birth
Gender / Ethnic Origin
Home Address
(inc. postcode) / Current address (if different)
Telephone number / Alternative tel. number
Language – interpreter needed? / Disability
(if any)

INDIVIDUAL CHILD / YOUNG PERSON / ADULTHISTORY

Is the individual or other children in the home known to social services?
Has a CAF assessment or statutory assessment been completed?
Any other relevant information

Section B

FAMILY DETAILS

Name of family / Alternative name of family
Main address
(inc. postcode) / Alternative address
(if different)
Telephone number / Alternative tel. number
Language – interpreter needed?
Home ownership
(please tick)
Owner occupied
Private rental / Name of landlord
Housing association / Name of housing association
FAMILY DETAILS
Surname / First name / Relationship to family members / DOB/
EDD* / M / F / PR**
(tick) / CR*** / Ethnic Origin / Disability
( y / n)

* DOB/EDD – Date of birth / Expected delivery date (for unborns)

** PR – Parental Responsibility

*** CR – Caring Responsibilities (to identify anyone who provides care for another member of the household)

FAMILY HISTORY

Is anyone within the household (adults or children) known to social services?
Has anyone within the household had a CAF assessment or statutory assessment of their needs?
Any other relevant information

FURTHER COMMENTS

Please give as much information as possible to give a clear indication of the needs, including strengths.
Strengths:
.
Are there any known risks / concerns to be considered?
Please detail what you, the child/young person/adult and family are aiming to achieve with this referral.

Go to Section C

Section C

Other Agencies Involved – DETAILS

Nursery / School / College / Employer:
Name:
Address:
Telephone number: / Email address:
GP Details:
Name:
Address:
Telephone number: / Email address:
Health Visitor / School Health Adviser:
Name / Role / Agency:
Based at:
Telephone number: / Email address:
Other agency involvement:
Name / Role / Agency:
Based at:
Telephone number: / Email address:
Other agency involvement:
Name / Role / Agency:
Based at:
Telephone number: / Email address:
Other agency involvement:
Name / Role / Agency:
Based at:
Telephone number: / Email address:
Other agency involvement:
Name / Role / Agency:
Based at:
Telephone number: / Email address:
Go to Section D
Section D
PRESENTING NEEDS
Please tick all boxes that apply and assess which level of need you think is the starting point for support.
Stay Safe

Absconding/staying away from home

Victim of hate crimes

Aggressive/violent behavior (parent/carer)

Working with social care
Other Please state: /
Instances of domestic abuse in household

Family involved in criminal activity

Aggressive/violent behaviour (individual)

Lack of guidance / supervision / parenting
Living with known offenders
Degree to which child / young person / adult / family is achieving this Outcome:
No concerns. / May need extra support. / Presenting complex needs which require co-ordinated support. / Intensive support required.
Be Healthy

Poor mental health (parent/carer)

Alcohol misuse (parent/carer)
Substance abuse (parent/carer)
Poor physical health (parent/carer)
Diagnosed condition (parent/carer)
Please state …Mum has cancer…………………………
Other Please state: /
Poor mental health (individual)

Alcohol misuse (individual)
Substance abuse (individual)
Poor physical health (individual)
Diagnosed condition (individual)
Please state ……………………………
Unsafe / early sexual activity
Degree to which child / young person / adult / family is achieving this Outcome:
No concerns. / May need extra support. / Presenting complex needs which require co-ordinated support. / Intensive support required.
Enjoy and Achieve

Instances of exclusions

Truancy

NEET or at risk of NEET*
Other Please state: /
Low motivation to achieve /
limited aspirations

Engaged with local services

Displays behaviour that impacts on
ability to enjoy and achieve
Degree to which child / young person / adult / family is achieving this Outcome:
No concerns. / May need extra support. / Presenting complex needs which require co-ordinated support. / Intensive support required.
* NEET – not in employment, education or training
Economic Well-Being

Lived in care / living in care

Living at no fixed abode

Part of a workless household

Low income / Eligible for free school meals
Other Please state: /
Behaviour is affecting own and/or
parental education/employability

Living in unsuitable housing conditions
Please describe……………………………

Debts / At risk of losing their home
Degree to which child / young person / adult / family is achieving this Outcome:
No concerns. / May need extra support. / Presenting complex needs which require co-ordinated support. / Intensive support required.
Positive Contribution

Pro-criminal peers

Lack of age-appropriate friends

Non-constructive use of time

Level of crime in the area
Involvement in ASB /
criminal activity (parent/carer) /
Perpetrator of crimes, including hate crime
Known offender on Statutory Order
Concerns over potential involvement
in ASB / criminal activity

Involvement in ASB /
criminal activity (individual)

Other Please state:
Degree to which child / young person / adult / family is achieving this Outcome:
No concerns. / May need extra support. / Presenting complex needs which require co-ordinated support. / Intensive support required.

Please go to Section E.

Section E

CONSENT

I confirm that I have discussed this request for involvement with the individual and/or family.
Signed………………………………………………. Name…………………………………… Date……………………….
(Referrer)
INDIVIDUAL / FAMILY
I have had the Family Support Service explained to me and agree to this request for involvement from the service.
I understand that the information recorded on this form and other information obtained about me and my family / household will be shared with the Family Support Service and other relevant agencies, which may include health, education, social care, adult services, housing, police and any other services that are relevant for my situation. I am aware that I may limit the information shared and that I may withdraw consent at any time.
Please tick as appropriate:

I agree to this request for involvement.

I consent to all of the information in this form being shared between the agencies outlined above.
I consent to some of the information in this form being shared between the agencies outlined above, but would like to restrict access to any information associated with*:
……………………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………..
*If full consent has not been obtained, please detail why:
……………………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………..
Child / Young person / Adult / Parent/carer / Parent/carer
Print name: / Print name: / Print name:
Signature: / Signature: / Signature:
Date: / Date: / Date:

Amended Oct 2013 (al) v2

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