Referral to Barnardo’s Pan London Service for Sexually Exploited, Missing and Trafficked Children Services Family Support.

Type of referral:
(Please tick) / Social Care Agency ☐ Barnardo’s CSE Worker ☐
Other External Agency ☐ Self ☐
Agency Name:
Referrers name and Job title:
Involvement with family:
Telephone:
Email: / Address:

Parent/Carer:

Name: / D.O.B.
Address including postcode: / Contact phone number :
Relationship to child / Young Person: / Do you have parental responsibility over the young person?

Other Adults living in household:

Name: / Relationship to child:
Name: / Relationship to child:

Child(ren) Details

Childs full name / Date of birth/ or EDD / Age / Male or female? / Disability
Y/N / Educational Establishment attending? Primary School / Secondary School / College

Barnardo's has an ‘open access policy’. Referrers should therefore bear in mind that any information included in this form may be shared with the parent. Our Confidentiality Policy for young people states that ‘any secrets or concerns you choose to share with us will be kept within the project – unless you want us to talk to somebody for you, or you or someone else is in great danger’

Outcomes that have been identified and need Family Support work:

Enhancing Parent / Carer Adult Child Relationship ☐

Parent(s) need support with holding open conversations with child / young person expressing fears, feelings, insecurity and anxiety ☐

Parents need healing and road to recovery in partnership with young child

(Present, pre or still on going CSE) ☐

Helping parent(s) to continue work with Barnardo’s CSE Team ☐

Parent(s) need support in breaking barriers and accessing appropriate support services ☐

Parent(s) need support with understanding what CSE is and help with identifying signs ☐

Reason for Agency referral:

Barnardo's has an ‘open access policy’. Referrers should therefore bear in mind that any information included in this form may be shared with the parent. Our Confidentiality Policy for young people states that ‘any secrets or concerns you choose to share with us will be kept within the project – unless you want us to talk to somebody for you, or you or someone else is in great danger’

(Any Significant new safeguarding or current safeguarding Issues around family )

Other Professionals Involved: Inc any other agencies working with the family.

Name of professional / Organization: / Contact details: / Email

Please tick this box both to confirm parent’s consent to this referral and that information on the form will be used to enable staff to offer appropriate support and will be kept in accordance with Data Protection Act 1998

Signature of referrer: ______Date ___/____/______

(Parent or Agency): Please Delete applicable

Signature of referrer: ______Date ___/____/_____

(Parent or Agency): Please Delete applicable

Signature of referrer: ______Date ___/____/______

(Parent or Agency): Please Delete applicable

Barnardo's has an ‘open access policy’. Referrers should therefore bear in mind that any information included in this form may be shared with the parent. Our Confidentiality Policy for young people states that ‘any secrets or concerns you choose to share with us will be kept within the project – unless you want us to talk to somebody for you, or you or someone else is in great danger’