Referral Form to Children and Families

SafeguardingChildren Board

Referral Form to Children and Families

This form should alwaysbe completed when making a referral in respect of a childwith complex needs or in need of safety and protection.

All urgent child protection referrals should initially be made by telephone to the Duty Desk on 686179 and then confirmed in writing within 24 hours using this form. If it is out of hours, please phone 631212 and the Police will contact the out of hours duty social worker. The form should then be sent to the Duty Team, Children and Families, 2nd Floor, Murray House, Mount Havelock, Douglas IM1 2SF or by email to

You must ensure that you follow your own agency procedures re notifying relevant designated child protection officer or your line manager of this referral.

Is this a new referral? YES/No/ Not Known

If there has been a previous referral when was it made? Date:

Or is this additional information on a case already open to Children and Families? YES/NO

Child/Young Person
Forename(s) / Surname / D.o.B. / Address / Tel. No.

Reason for the Referral Please give brief details describing what your agency may have already provided to the family

Have the parents/carers given informed consent for the referral to Children and Families? YES/NO
If not, why not?
Is the child/young person of an age and understanding where they may give their own consent? YES/NO
* (By informed consent this means they know they can refuse and understand that the referrer may have justifiable cause to share the information).
Children and Families Service should ensure that they do not accept the referral unless the issue of consent is addressed.
Other household members. (Specify who holds parental responsibility)
Forename(s) / Surname / D.o.B / Relationship / Also Referred?
Yes No
Yes No
Yes No
Yes No
Yes No
Contact Details for other significant adults not living in the household
Forename(s) / Surname / D.o.B. / Relationship / Address / Tel. No.
School (s)
GP
Child/Young Person’s ethnicity, religion and communication needs
Ethnic Origin
1st Language / (Is an Interpreter/Signer required?) Yes/No
Religion
Any specific factors that you know of, about which professionals need to be awaree.g. history of violence/hazards?
How long has the child/young person lived in the Isle of Man?
Please supply details of previous addresses if known:
Are you aware of any other agencies involved?
Name / Designation / Address / Tel. No.
Has the child /family previously had a Child with Additional Needs Plan (CWAN)?
Yes/No
If so, when?
Please outline any earlier interventions that you are aware of to address any previous concerns.

Assessment of Needs

Please give as much information as possible based on the Assessment Framework triangle.

our assessment triangle jpg

Child’s Developmental Needs
Parenting Capacity
Family and Environmental Factors
Dynamic Risk Assessment:
Describe the risks,impact and protective factors for the child. / Risk:
Impact:
Protective Factors:
Details of Referrer
Name
Designation
Address
Email / Tel. No: / Mobile No:
Date of telephone referral if applicable
Have you discussed this referral with your designated child protection officer or your line manager? Yes/No
If not, why not?
Signed
Print Name
Designation
Date

FOR COMPLETION BY CHILDREN & FAMILIES

(This page must be sent to professional referrers)

Name of Child/Young Person:

OUTCOME OF REFERRAL

Reasons for decisions made

Parents/Carers informed of outcome of this referral? Yes No

Senior Social Worker (please print name):

Signature: Date:

Referral Process to Children and Families Section