Single Agency Referral Form

Single Agency Referral Form

This form is to be used when making a referral into Children’s Social Care, or for a referral to a single agency or for Early Help. The form should be completed with consent unless the referral is due to child protection concerns and to approach the child/young person/parent/carer would mean an increased risk of significant harm, prejudice the prevention or detection of crime, or place an adult at risk of significant harm.

Date of Referral: / Click here to enter a date. /
Agency Referred To: / Choose an item.
If ‘other’ please specify:
Section 1: Referrer’s Details
Name & Designation:
Address:
Telephone: / Email:
Section 2: Child/Young Person’s Details
Name:
Gender: / Choose an item.
Date of Birth: / Click here to enter a date. /
Address:
Telephone
Language
Ethnicity / Choose an item.
Religion / Choose an item.
Parent/Carer’s first language
Does the child have an identified Special Educational Need? / Choose an item.
If yes, which are the main areas of need? / Choose an item.
Education & Health Care Plan? / Choose an item.
If yes, please provide details.
Do you consider the child to have a disability, as defined by the Equality Act 2010? / Choose an item.
Section 3: Reason For Referral
Details:
What work has already been completed to support this child and/or family?
What are your service and the child/family expecting from this referral?
Section 4: Details of parents/carers and family
Name: / Relationship:
Address (if different)
Name:
Telephone: / Parental Responsibility: Choose an item.
Please list below any other children or adults within this family/household
Name- DOB/Age / Relationship
Section 5: Services working with this child and/or family
Please list below any agencies working with this family (eg GP, Health Visitor, School)
Section 6: Risk Assessments
Are there any known risks if a home visit was to be carried out? / Choose an item.
If yes, please provide details.
Section 7: Supporting Documents
Are you providing any documents or separate information to support this referral?
If yes, please provide details.
Section 8: Consent
Is the parent/carer aware of this referral? / Choose an item.
If not, please detail why this referral is being made without consent
Is the child/young person aware of this referral? / Choose an item.
Comments of parent/carer and or child/young person
In submitting this form, I confirm that I have obtained consent, as appropriate, and that the parent/carer and/or child understand that information will be shared (as appropriate) between relevant professionals including the Trafford Care Coordination Centre.

SARF V15