Fern Street Office Use only
Lamplight Case Number

Family Support Referral Form

Please use this form to refer a family to Fern Street Settlement for Family Support. If a Common Assessment Form/Early Help Assessment is available, please attach/enclose a copy of this.

This form can be returned by email to: or by post to Fern Street Settlement, Fern Street, London, E3 3PS. If you have not heard from us within 3 working days of submitting your referral, please call us on 02079871949 and ask for Joanna or Sara.

This form will be held in confidence, but may be shown to the family if requested.

Please note all referrals must be made with the consent of the family.

Yes / No

Have you discussed this referral with the family before completing this form?

We prioritise referrals for families with children aged 11 and under, living in E3 or E14 postcodes

SECTION 1: CHILD’S DETAILS SECTION 2: REFERRER’S DETAILS

CHILD’S DETAILS
Date of referral
Child’s First name / Surname
Date of Birth
Address
Languages spoken / Interpreter required? / Yes/No
Religion / Ethnicity
REFERRER’S DETAILS
Name
Job Title
Organisation
Address
Telephone Number
Email

SECTION 3: CURRENT PLANS

Plans (please tick √ ) / Lead Professional / Contact details / Date of next meeting
Child Protection Plan
Child in Need
CAF / EHA
History of social care involvement? / Yes / No

SECTION 4: MAIN CARERSPlease provide details of the main adults caring for the child(ren)

Name / DOB / Contact Number / Parental Responsibility √ / Address / Interpreter required? √
Mother
Father
Other main Carer

SECTION 5: HOUSEHOLD MEMBERS

Other Children in household
Child’s Name (eldest first) / Gender / Date of birth / Immigration
Status / Considered disabled by main carer? √ / Ethnicity / School / Subject to CAF?: √ / Name of Lead Professional / Child in Need? √ / Child Protection Plan? √
Male / Female / Asylum seeker / Refugee / Pending / Bangladeshi
Pakistani
Indian
White British
White Irish
Eastern European
Other white
African
Caribbean
Mixed – Any
Chinese
Any other
C1.
C2.
C3.
C4.
C5.
C6.
Other Adults in household
Name / Position relative to child
e.g. mother, uncle, mother’s partner / Gender / Date of birth / Immigration
Status / Considers self to have a disability? √ / Ethnicity / Religious belief?
Please specify
Male / Female / Asylum seeker / Refugee / Pending / Bangladeshi
Pakistani
Indian
White British
White Irish
Eastern European
Other white
African
Caribbean
Mixed – Any
Chinese
Any other

SECTION 6: – SIGNIFICANT OTHERS

Position / Name / DOB / Contact Number / Parental Responsibility √ / Address / Interpreter required? √
(please specify language)

SECTION 7: OTHER PROFESSIONALS

Please provide details of other agencies involved in supporting the family (e.g. Children’sServices, Police,Probation Services, Drug and alcohol etc)

Name / Address / Contact Number / Email / Any action already taken
G.P
Health Visitor

SECTION 8: SUPPORT REQUIREDTo help us offer the family the most appropriate support, please complete the table below:

Support required / X / Please give further details
Parenting Capacity
Parenting Skills
Parent-child relationship
Coping with multiple birth/multiple children under 5
Managing own (parent) mental/emotional health
Managing own (parent) physical health
Parent’s Self-Esteem
Ensuring Safety
Drug/Alcohol/Substance Misuse
Child’s Needs
Additional needs
Play / Stimulation
Behavioural/Emotional difficulties
Coping with child’s mental health needs
Coping with child’s physical health needs
Basic Nutritional Support
Family/Environmental Factors
Housing (please note we able to offer very limited support with housing)
Managing benefits/household budget
Domestic violence/abuse
Isolation
Family Conflict
Accessing services / facilities in area

SECTION 9: ADDITIONAL INFORMATION: Please provide any additional information that would be helpful to us in supporting the family below

SAFETY & RISK
Are there any safety issues to consider when visiting the family at home or elsewhere?
(Example: Domestic violence, drug/ alcohol misuse, mental health issues) / Yes / No
If Yes, please give details:
Parent Signature / Date
Referrer’s Signature / Date

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