(Mon – Thurs 8.45am – 5.00pm, Fri 8.45am – 4.30pm):
Emergency Duty Service (Immediate Out of Hours Response) No: 0345 606 1212 (Mon - Thurs 5.00pm – 8.45am, Fri 4.30pm – Mon 8.45am Inc. Bank holidays)
(for non-immediate requests please contact the Children & Families Hub within the working hours above) / By Email to: (PLEASE EMAIL SECURELY)
By Post to: Children & Families Operations Hub, Essex House, 200, The Crescent, Colchester, Essex CO4 9YQ
By Fax to: 03330 133944
What action have you taken to help the family with the concerns?
Have you used the consultation opportunity at the Family Operations Hub? If not why not?
Call 0345 603 7627 and ask for the Consultation Line
REQUESTS ARE NOT ALWAYS REVIEWED IMMEDIATELY UPON RECEIPT.
DOES THE CHILD/REN REQUIRE IMMEDIATE PROTECTION?
IF YES – Call the 0345 603 7627 and ask for the CHILDREN & FAMILIES HUB PRIORITY LINE
and/or contact Essex Police (999 or 112)
SECTION 1 - Consent: The parents’ permission should be sought before discussing a referral about them with other agencies, unless permission seeking may itself place a child at risk of significant harm. SET Procedures 2.4.11 (2015) The referrer should not refrain from making a referral because they lack some of the information as the welfare of the child is the priority. SET Procedures 2.4.1 (2015)1. a Please state who within the family has been informed of your concerns and this request for support?
(names & roles within the family)
1. b Who within the family has given consent to share their information put in this request for support?
(names & roles within the family) Written Consent Verbal Consent
if 1a & 1b has not happened, please explain why (clearly outlining the risks involved with informing the family)
Are there any safety issues / hazards to be aware of? / Yes / No / Unknown
If yes please specify:
CHILD/REN / YOUNG PERSON’S DETAILS:
First Name / Surname / DoB/ EDD / Gender / Ethnicity / First Language / Beliefs / Disability Y/N
`
Any other relevant information e.g. Interpreter/ Signer required; nature of disability:
PARENTS / MAIN CARERS AND SIGNIFCANT OTHERS/ HOUSEHOLD MEMBERS:
Name / DoB / Relationship to child / young person / Ethnicity / First language / Beliefs / Parental Responsibility
Yes / No / NK
/
Yes / No / NK
/
Yes / No / NK
/
Yes / No / NK
/
Any other relevant information e.g. Interpreter/ Signer required; nature of disability:
Child/rens Main address (including postcode): / Home Tel no:
Mobile no’s:
Current address if different (e.g. staying with a relative): / Home Tel no:
Mobile no’s:
SECTION 2 – REQUESTOR DETAILS:
Name: / Agency:
Phone No: / Address: (including postcode)
Professional role:
Email Address:
(Please use a secure email address or follow your Information Governance Procedures)
Who is requesting a service from Children & Families? / Requestor / Parent(s) / Child / Young Person
What is your current involvement with the family?
This is confirmation of a request I made by telephone to the Children & Families Hub on (date) to (C&FH Member of staff):
Signature: Date:
AGENCIES INVOLVED WITH THE CHILD/REN / YOUNG PERSON/FAMILY :
Agency / Name / Phone No. / Agency / Name / Phone No.
Health Visitor / Probation / Youth Offending Team
Midwife / Family Solutions
Other Community Health Services / Counsellor
Early Years / Child Care Settings / Adult Mental Health
School / Emotional Wellbeing and Mental Health Services
School Nurse / Other, please state
General Practitioner
SECTION 3 – REASON FOR REQUEST
What are your concerns for this child/ren/Family?
Is there actual harm? – what action is causing the harm;
What is the factual information and evidence base specific to your concern;
What are the future dangers for this child(ren)/family should this concern not be addressed?
What are the complicating factors for this child(ren) and/or family that makes the concern more difficult to deal with? / What is going well for this family and what resources/services are already in place?
What is going well? – what is making things go well?
What existing support is in place for this child(ren)/family that has been tested and proven to alleviate the concern;
Are there resources (eg family/friends/community) being accessed or services that are being provided to address the concern?
What are the views of the child(ren)/family? / What needs to happen next?
What changes do the family need to make for your concern to be addressed? Please list the changes and outcomes you think are needed.
What changes do the family think they need to make? What do they think would help them?
What do you think would help to decrease the concern and risk to this family/child/ren?
How can Family Operations help the family to make the changes you have identified?
SECTION 4: Family Consent to Share Information
This page is to be completed once you have gained consent from the family to submit this request
This section should be completed by a family member with parental responsibility.
Please read carefully, complete the restriction box if appropriate, then sign and date the form. If you have concerns please discuss them with the person working with you.
I agree that personal information about me / my /our child(ren) may be shared with or requested from other agencies and with other professionals, so that my family’s needs can be assessed, or I / my / our child(ren) can be provided with services.
I agree that personal information about me / my children can be used for research to develop local and national practice (which will be suitably anonymised) and contribute to understanding needs across Essex.
I agree that personal information about me / my child(ren) may be shared with or requested from other professionals, so that I / my / our child(ren) can be provided with services and evidence the effectiveness of involvement both during and post involvement.
I understand that I have the right to restrict what information may be shared and with whom, however information can be shared without consent in order to safeguard the vulnerable, to prevent crime and/or if ordered by a Court.
I understand that I may withdraw my consent to share information at any time and this may result in a reduction of services being available.
Information I do not want to be shared:
Full Name of Main Family Contact / DOB: / NI Number
Signature of Main Family Contact / Date: / Contact Numbers
Family Address: / Postcode:
Email Address:
IMPORTANT –THE SECTION BELOW MUST BE COMPLETE FOR FAMILY SOLUTIONS/SOCIAL CARE TO BE CONSIDERED (GOOD PRACTICE)
The main family contact needs to sign beside any member of the Family that is aged 15 or under.
Any family member over the age of 16 needs to give consent for the above by signing against their details.
First Name / Surname / Signature of consent to the above / First Name / Surname / Signature of consent to the above
In order to alter your consent, please inform the person working with you.
This consent form should be reviewed at the completion of any new assessment to ensure it remains an accurate reflection of the families’ wishes.
Statement of Information Sharing for Professional supporting the completion of this form
Op[op
Name: / Signature:
Organisation: / Date:
Is the person able to understand why their information may be shared and are they able to make a consent decision on this basis?
Please tick to indicate the section you have completed ( A or B or C below).
A YES and I have explained to the person/their representative:
Why we may need to share information.
Who we may need to share information with – for example:
Police; Probation; Essex County Council i.e Social Care, YOT, EWS; Target Youth Service; Department of Work and Pension; Employment and Skills; District Housing Departments and Providers; Health Providers i.e. Adult Mental Health, CFCS or General Practitioners; ECC Contracted Partners; School/ Education Providers; Third sector providers who are or who may work with the family.
Their right to decline the sharing of some or all of the information. Their right to withdraw consent at any time.
The person has signed this form overleaf
That in some cases we may share information without consent in order to safeguard the vulnerable, to prevent crime and/or if ordered by a Court.
B I am unable to judge this and have referred this matter to:
or
C No, because:
Statement of representative (only to be completed where there may be a concern regarding the individuals capacity to make decision).
I represent the person named on this form and: / Date: ______Relationship to Person: ______
I agree with decisions that have been made concerning the sharing of information
I do not agree with the decisions that have been made concerning the sharing of information because: / I do not agree with the decisions that have been made concerning the sharing of information because:
Signature: ______Date: ______Relationship to Person: ______
Source of Legal Authorisation, if applicable (for example Legal Power of Attorney):
Privacy Notice - For full details on how Essex County Council – Family Solutions service process your personal information, visit: http://www.essex.gov.uk/Your-Council/Your-Right-Know/Documents/Family-Solutions-Privacy-Notice.pdf
REASON FOR REQUEST (continuation sheet):
Is there any other information which is important to this family or for professionals to know about?
Section 4: Frequently Asked Questions about Information Sharing
(To be left with the Family)
Why share personal information?
Sharing personal information helps us to work together to support children, young people and their families and carers. But, it is important to remember that if you don’t let us share your information, this could delay or prevent you from getting the help you need.
Can I choose what personal information is shared about me?
Yes, most of the time we will tell you what information we might need to pass on and who we need to pass it on to. The types of information to be processed may include: Name, Date of Birth, Gender, Address, and relevant information to inform assessment. Most of the time, if there is something that you don’t want us to pass on about you then we won’t. Please tell the person working with you.
Sometimes we have to share personal information about you without asking your permission, for example:
• If we are worried about the safety of a child, young person or vulnerable adult;
• If we think that a crime may be prevented or found out by sharing it; or
• If a court order is made in criminal or legal cases
Can I say no?
• You can ask us not to pass your personal information to anyone else at any time
• You can say no at first. You can always change your mind later on
• Or if you say yes you can also change your mind later on
How will I gain from sharing my personal information?
• It will help us make sure that you get the right sort of help
• You can quickly find out about the different types of help available to you
• You won’t be asked for the same information lots of times
How do we share personal information?
So that we can safely share your personal information, some organisations in Essex such as Essex County Council, Health and the police have signed an agreement called the Essex Trust Charter. This means that all the organisations that have signed it must protect your personal information. For details of the charter and the organisations involved, ask the person that is working with you or you can find it on the internet at Essex partnership portal
Can I see what is on my record?
Yes. If you want to check your own record or talk to someone about how safe and confidential your personal information is, you should talk to the person who is working with you.
Data Protection:
For independent advice about data protection, privacy and data sharing issues, you can contact the Information Commissioner’s Office, Wycliffe House, Water Lane, Wilmslow, Cheshire, SK9 5AF. Tel: 01625 545745 or 08456 306060 Fax: 01625 524510 Website: www.ico.gov.uk
Children & Families Request for Support (06/17) Page 5