Surrey Family Support ServiceSelf-Referral Form

The Surrey Family Support Service works with families who are experiencing difficulties and would like support to help them make positive change. Families that are eligible for the service will usually have two or more of the following concerns within their family unit:

  • Mental or Physical Health needs
  • Historic or present domestic abuse
  • Involvement in crime or anti-social behaviour
  • Children with low attendance at school or behavioural problems.
  • Children in need of additional help and support within the home.
  • A parent or Young Person out of work and without a clear pathway into work.

Name of referrer
Family details – Parents or adult carers
Name 1:
Relationship
Gender / Date of birth
Address and postcode
Telephone (Home) / Mobile
Email Address
Religion
Ethnicity / NI number
Disability
(If yes, please describe)
GP Name and Address
Name 2:
Relationship
Gender / Date of birth
Address and postcode
Home Telephone / Mobile
Email Address
Religion
Ethnicity / NI number
Disability
(if yes, please describe)
GP Name and Address
Children / Young People / Date of birth / Gender / SEND* / Education Details
Name 1:
Name 2:
Name 3:
Name 4:
Name 5:
Name 6:
Name 7:
Name 8:
Name 9:
Name 10:

*SEND = Special Educational Needs and Disability

Please tell us a little bit about your family situation and list the top three things you would like the support to change.

Surrey Family Support Team Managers – Contact Details

Consent to information sharing:

Sharing information helps us to better assess your family’s needs, which will enable us to work with you in ways that ensure we help you access the most appropriate services. Your consentis at the centre of information sharing. When we ask your permission to share information, we will always explain what information we are seeking, how we will use the information and who we will share the information with.

1. I have had the Surrey Family Support Programme Information Sharing Protocol explained to me, I have had the opportunity to have any questions and I am satisfied that I understand who my personal information will be shared with and the reasons for this, and that my participation in this programme is entirely voluntary.

2.I agree that my personal information will be shared between the agencies listed below for the purposes of providing support to my household, as well as for necessary audit purposes and for improving this service in future.

3.I understand that this personal information will not be provided to third parties unless there a clear legal justification for doing so (such as in the case of child protection or preventing crime or disorder).

Name (Please print)
Signature
Role in Family
Date

We can work with a range of different agencies, including schools, Education Welfare, Police, Youth Services, Probation, Housing, Adult Social Care, Children’s Social Care, Health, CAMHS, Adult Mental Health Services, Substance Misuse Services, and DWP. Please advise us if there are any specific agencies or organisations you would like us not to share information with.

Please be aware that if you have disclosed any information on the form that indicates that someone is at significant risk of immediate harm, we have a duty of care to report this information to the appropriate organisation. We will not need your consent but we will advise you of any actions we take.

Family Support Team / Manager / Telephone / Email / Address
Surrey Heath and Runnymede / Emily Bell / 01276707333 /
For referrals:
/ Surrey Heath Borough Council, Surrey Heath House, Knoll Rd, Camberley, GU15 3HD
North East (Epsom & Ewell, Elmbridge and Spelthorne) / Charlene Edwards / 01372 474382 /
For referrals:
/ Elmbridge Borough Council, Civic Centre, High Street, Esher, Surrey, KT10 9SD
Guildford / Helen Dowlatshahi / 01483 444089 / For referrals: / Guildford Borough Council, Millmead House, Millmead, Guildford, Surrey, GU2 4BB
South East
(Reigate & Banstead, Mole Valley and Tandridge) / Duane Kirkland / 01737276316 /
For referrals:
/ The Town Hall, Castlefield Road, Reigate, RH2 0SH
Waverley / Julie Shaw / 01483 523245 / For referrals:
/ Waverley Borough Council, Council Offices, The Burys, Godalming, Surrey, GU7 1HR
Woking / -Adam Thomas / 01483 743812 / For referrals:

Tel: 01483 743812 / Woking Borough Council, Civic Offices, Gloucester Square, Woking, Surrey, GU21 8YL

If you want any further information then please contact one of the above teams or visit our website: