Spurgeons (Peterborough) Referral Form

Please note: written consent/ signature is required from parent(s)/ carer(s) named on this referral form

General referral information
Referral to: / Orton CC (South) Honeyhill CC (North, West Rural)
Support Requested: / Universal Support Access to Groups Baby Massage Family Support Enjoy Parenting (18mths-4yrs)Webster Stratton (3-6yrs) Freedom Programme Other (please state):
Tier Level: / 1 (one) / 2 (two) / 3 (three)
Date of referral: / Time of referral:
Name of referrer: / Position held:
Referrer’s work place: / Referrer’s email:
Referrer’s work place office/direct line tel: / Referrer’s working hours:
Child being referred (must be 0-5 years old)
First Name(s): / Last Name:
DOB: / Ethnicity:
Address:
Postcode:
LL Number: / eStart Number:
Parent/Carer 1 / Parent/Carer 2
Name: / Name:
DOB: / DOB:
Ethnicity: / Ethnicity:
Address: / Address:
Post Code: / Post Code:
Telephone: / Telephone:
Mobile: / Mobile:
Parental responsibility: / Yes No / Parental responsibility: / Yes No
Is it safe to contact: / Yes No / Is it safe to contact: / Yes No
Preferred Method: / Preferred Method:
Safe Times: / Safe Times:
Siblings:
Name / DOB / Ethnicity / Relationship / Education Status / Living at above address?
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Crèche (for Enjoy Parenting, Webster Stratton, Freedom Programme)
Is a Crèche place(s) required: / Yes No Unknown
Name of Child(ren)
Please explain the current situation/reason for referral: including area’s of support needed:
Are there any specific needs arising from race, culture, religion, language and/or disability for this family?
Are you aware of any particular health & safety issues/potential risks which staff supporting the family need to be aware of?
Are you aware of any historical information which may be relevant today?
Times referred child is not available (i.e. at school, with childcare provider, staying with other family member)
Monday / Tuesday / Wednesday / Thursday / Friday
AM
PM
Times parent/ carer are not available (i.e. working, volunteering, training, child(ren) drop off / collection from school or childcare provider)
Monday / Tuesday / Wednesday / Thursday / Friday
AM
PM
Professional Involvement
Are any other agencies involved with the family: YesNo
Agency / Staff Name(s) / Address/ Email / Telephone
Please give any specific details below (including historical dates/ information if known, i.e. previous Children’s Social Care involvement):
LAC:
Child Protection Plan:
Child In Need:
MASG:
TAC:
TAF:
Other (please state): / YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
Current and historical supporting documents(please attach to email or send a link to relevant folder at to and )
Early Help Assessment
C&F Assessment
Child Protection Plan
Outcome Star
Meeting Minutes
Risk Assessment
Letter(s)
Other (please state) / YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo

Please note: written consent/ signature is required from parent(s)/ carer(s) named on this referral form

Agreement:
Is the family aware of this referral? / YesNo
Supporting documents attached with parent/carer consent? / YesNo
Name of referrer: / Name of Parent/Carer:
Signature of Referrer: / Signature of Parent/Carer
Date: / Date:
Please return this form to:

Referral Form submission

Please return this form to:

Hand delivered and/or posted forms will no longer be accepted

Project/Centre Use Only
Referral number: / Date received:
Date added to system: / Date of first appointment:
LL linked number(s):
eStart linked number(s):
If the case is not being worked with please identify why:

Case File Structure – Final – Referral Form – 16/05/2017Spurgeons Peterborough CC’s1