REFERRAL AND INFORMATION RECORD

(To be used by agencies when making a referral to Children’s Social Care – A written referral must be made within 48 hours of a verbal referral)

Child/Young Person’s name, address and responsible Local Authority
Surname: / D.O.B:
Forenames: / Gender (box) / Male / Female / Unspecified
Address:
Post Code: / Current address (if different)
Post Code:
Telephone No: / Mobile: / Day: / Evening:
Is the parent/carer aware of the referral? ( box) / Yes / No / Re-referral:
Child/Young Person’s Principal Carers
Name / Relationship to child/young person / Parental Responsibility
Yes / No
Yes / No
Child/Young Person or other family member(s) has/have been looked after by a Local Authority ( box) / Yes / No / Authority Name:
Referred by: / Relationship to Child/Young Person:
Address:
Post Code:
Telephone Number: / Date of Referral:
Child/Young Person’s Ethnicity ( box)
Caribbean / Indian / White British / White & Black Caribbean / Chinese
African / Pakistani / White Irish / White & Black African / Any other
Ethnic Group
Any other black background / Bangladeshi / Any other
White background / White and
Asian / Not Given
Any other Asian Background Any Other Mixed Background
If other, please specify
Child’s first Language / Parent/Carer(s) first Language
Is an interpreter or signer required to communciate with the family? / Yes / No
Other household members (including non-family members)
Surname / Forename / D.O.B. / Nursery/School / Relationship to child
Significant family members who are not members of child’s household
Name: / Name:
Relationship: / Relationship:
Address: / Address:
Tel: / Tel:
Name: / Name:
Relationship: / Relationship:
Address: / Address:
Tel: / Tel:
Key agencies (please if currently working with the family) (please add additional names if required)
G.P. / Tel: / Attendance Officer / Tel:
Nursery / Tel: / Police / Tel:
School / Tel: / Community Pediatrician / Tel:
Y.O.T. / Tel: / 0 -19 Service Health / Tel:
CYPS / Tel: / Housing / Tel:
Other (specify) / Tel: / Other (specify) / Tel:
Other (specify) / Tel: / Other (specify) / Tel:
What Supports are currently in place?
Start typing below (box will expand if required)
Reason for referral/request for services: Identify strengths as well as needs
Considering: Parenting Capacity, Child Development,
Family Environmental and Risk factors. (See Assessment Diamond overleaf)
You must state the nature of concern or perceived
risk in as much details as possible
Start typing below (box will expand if required)

Name of person (completing this form)
Signature
Date

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Form updated March 2017