Surrey Family Support Programme

Surrey Family Support Programme

REFERRAL FORM

This form allows individual practitioners within agencies, organisations and multi-agency community groups to refer families into the Surrey Family Support Programme.

Meeting the criteria

In order to be eligible for the programme a family must meet one or more criteria from at least two of the following categories:

Category 1. EDUCATION

Child has 15% unauthorised absences or more across the last three consecutive terms.
Child subject to a permanent exclusion.
Child subject to three or more fixed school exclusions across the last three consecutive terms.
Child in a Pupil Referral Unit (PRU) or alternative provision because of previous exclusion.
Child not on a school roll.
Child has a pattern of poor attendance that gives the headteacher an equivalent level of concern. Authorised absence may be taken into account where there is a comparable attendance problem masked by recording practises

Category 2. WORK

Adult on Department of Work and Pensions (DWP) out of work benefits.
Adult on Employment and Support Allowance.
Adult on Incapacity Benefit.
Adult on Carer’s Allowance.
Adult on Income Support.
Adult on Severe Disablement Allowance.
Adult on Jobseekers Allowance.

Category 3. CRIME AND ANTI-SOCIAL BEHAVIOUR

One or more under 18‐year‐old with a proven offence in the last 12 months (including Youth Restorative Intervention).
One or more family members of any age with an Anti-Social Behavioural Order (ASBO),

Anti-Social Behaviour (ASB) injunction or an Acceptable Behaviour Contract (ABC).

Family subject to a housing‐related ASB intervention in the last 12 months.
Correspondence/visit to family home relating to negative impact community behaviour in the last 12 months.

In the case of a family only meeting two of the above categories, then they will need to meet at least one of the following criteria:

Discretionary criteria: family of concern

 Children in need Risk of homelessness

 Domestic abuse NEET or risk of NEET

 Mental health issues Drug / alcohol problems

 Prisoner or ex-prisoner in family Multi-generational unemployment

Other reasons that cause professionals to have a concern about the whole family.

The multi-agency panels will use these criteria to prioritise families during the referral process.

It is appreciated that you may not know all the information required on the form. Please complete as much as you can. Your referrals are valued. Please email or send in an envelope marked private and confidential to your local Family Support Team.

If you have any queries in regards to completing this form or the service we offer, please don’t hesitate to contact us. ALL TEAM CONTACT DETAILS CAN BE FOUND AT THE END OF THIS FORM.

Please note: we are unable to accept any family onto the programme who has a child subject to a child protection plan.

Referrer details:

Name
Job title
Referring agency
Agency address
Telephone number
Email address
Date of referral

Family composition:

Name / Date of birth / Relationship / Ethnicity / Religion / Disability / National Insurance Number

Family contact details:

First line of address
Second line of address
County
Postcode
Home telephone number
Mobile number
E-mail address

Housing (if known):

Type of accommodation (please tick)
Permanent / Temporary
Local authority / Registered social landlord
Private rented sector / Owner occupier
Are the family facing any legal proceedings that threaten their housing?
Yes / No
If ‘Yes’, please detail:
Do any of the family members require any special arrangements, such as an interpreter?
Yes / No
If yes, please state:

Other known agencies engaged with the family (including your own agency):

Family member / Agency and contact / Work carried out to date or to be actioned

Category 1. EDUCATION

Name of child / Name of school or early years provider / Tick for
15% un-authorised absences or more over last 3 terms and state percentage / Tick if subject
to a permanent exclusion / Tick for 3 or more fixed exclusions in last 3 terms and state number of exclusions / Tick if at statutory age and not on school roll / Tick if Head Teacher is concerned about a pattern of poor attendance

Category 2. WORK

Name of adult / Tick if adult in the family is in work / Tick if adult in family is claiming benefits / Type of benefit claimed

Category 3. CRIME AND ANTI-SOCIAL BEHAVIOUR

Name of family member / Under 18 with proven offence in last 12 months / One or more family member of any age with ASBO, ASB or ABC / Housing related ASB in last 12 months / Correspondence / visit to family to address negative impact community behaviour in the last 12 months
Additional information relating to anti-social behaviour/offending, including any known criminal convictions:

Discretionary criteria:

Name of family members who meet the
discretionary criteria
(Tick appropriate column) / Child in need / Domestic abuse / Mental health issues / Prisoner or ex-prisoner in family / Risk of homelessness / NEET or risk of NEET / Drug / alcohol problems / Multi-generational unemployment / Other – please specify details below
If you have ticked other, please give more information here.

Risk management (if known):

Risk management - are you aware of any danger associated with home visits?
Yes / No
Please detail any risks such as dangerous dogs, syringes, violent family/visitors and attach a current risk assessment/risk management plan if available.

Any further information about the family of interest to the referral panel:

Family agreement and signature of referrer:

The family has consented to this referral being made and has agreed that the referrer may share the information provided with the relevant district and borough Family Support Programme (FSP) panel. Prior to submitting this form the family have also been given the FSP leaflet for their own information.
Tick to agree the family has given consent
Name of individual(s) within family who has given consent
Tick to confirm that the family has been given a Family Support Programme leaflet
Referrer signature
Signed / Date

Patchwork

Have you checked to see who else is involved with the family on Patchwork?
Yes / No
If no, please add your involvement with clients onto Patchwork to allow other professionals to find and contact you.
Go to: or contact for access.
Patchwork is a client-centred contact directory designed to help you find out who else is involved with the vulnerable children, young people and families you work with. It helps you understand the full picture, sometimes revealing hidden connections around a potentially vulnerable person, helping to prevent them slipping through the net.

Family support team managers – contact details

Elmbridge, Spelthorne, Epsom & Ewell
Team Manager: Charlene Edwards Tel: 01372 474382

General email:
Referral email:
Address: Elmbridge Borough Council, Civic Centre, High Street, Esher, Surrey, KT10 9SD
Guildford
Team Manager: Helen Dowlatshahi Tel: 01483 444089

General email:
Referral email:
Address: Millmead House, Millmead, Guildford, Surrey, GU2 4BB
Waverley
Team Manager: Julie Shaw Tel: 01483 523245
Email:
Address: Waverley Borough Council, Council Offices, The Burys, Godalming, Surrey, GU7 1HR
Woking
Team Manager: Philip Bell Tel: 01483 743812
Email:
Address: Woking Borough Council, Civic Offices, Gloucester Square, Woking, Surrey, GU21 8YL
Reigate & Banstead, Mole Valley and Tandridge (South-East Surrey Family Support Team)
Team Manager: Duane Kirkland Tel: 01737 276316
General email:
Referral email:
Address: The Town Hall, Castlefield Road, Reigate, RH2 0SH
Surrey Heath and Runnymede

Team Manager: Jacqueline Riddles Tel: 01276 707333
General email:
Referral email:
Address: Surrey Heath Borough Council, Surrey Heath House, Knoll Rd, Camberley, GU15 3HD