Early Help Notification Form Revised March 2018

Early Help Notification

Details of person requesting support Name Role Agency/organisation E-mail address Phone number

Before completing this form consider the need to obtain consent from the family, where this is necessary ensure the family understand the consent statement and agree with the content of this form prior to signing. Family information (please include other significant adults) Educational establishment Gender Relationship Any Ethnic NHS Name of DOB/ (M/F/ e.g. mother, declared School First name Last name origin No. school, EDD Un- father, child, diagnosed UPN attendance setting or known) grandparent disability rate (%) college

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Family contact details House no/name Street Town District Postcode

1 Early Help Notification Form Revised March 2018 Phone Email address numbers Other family addresses (if any) List family members living at this other address House no/name Street Town District Postcode Details of the request Select the primary reason for the request for support Click here to select from list Select the secondary reason for the request for support Click here to select from list Please state your reasons for making this request, outlining the issues, concerns, identified risks and reasons why support is needed

Please outline any work that has been undertaken with the family/individual by key agencies including any successes

Family/child/young person’s views: What is the family/child/young person hoping to achieve from this request and what do they feel their strengths are?

What is the intended outcome of Early Help & Preventative Services intervention? Early Help Notification

Are you aware of any issues regarding worker safety that should be taken into account when planning a response (including issues with behaviour)?

Additional Information: Details of other agencies/practitioners involved with the family (e.g. GP) Supporting Contact details If assessment has been Practitioner Team/ which Job role (work e-mail and undertaken please supply Name Organisation family phone number) details and dates member GP

Family Consent to Share Information (Include names and dates on electronic copy to indicate consent) I/We agree with the content of this form and understand the information gathered regarding my family is recorded and will be stored electronically and used for the purpose of providing advice and support for my family, and for the evaluation of this support. I/We agree to the sharing of information between the practitioners working with my family and that such practitioners might include, amongst others, family workers, youth workers, teachers, doctors, psychologists, nurses, therapists and social workers. I/We also agree that information provided on this form will be used to pre-register my family at our local Open Access Children’s Centre/Youth Hub, so that support can be easily accessed. For more information about how your information is stored and shared please see: https://www.kent.gov.uk/about-the- council/information-and-data/access-to-information/your-personal-information

IMPORTANT: Any family member over the age of 16 needs to give consent below. A young person aged 12 or over with sufficient understanding and ability to make their own decisions, may also provide consent. Name Signature Date

3 Early Help Notification Form Revised March 2018

Using the contact details you have provided we would like to send you information about activities and services offered at your local Open Access Children’s Centre/Youth Hub. Please tick if you would prefer not to receive this information: ☐

Notifier Checks The family have provided the necessary Yes No If no explain why: consent ☐ ☐ Yes No If no explain why: I have a signed copy of this form ☐ ☐ Yes No If no explain why: The family have been given a copy of this form ☐ ☐ Have the family seen the privacy notice Yes No If no explain why: available at www.kent.gov.uk? ☐ ☐

This notification must be sent to Early Help and Preventative Services via the secure Notification Upload Tool. This can be accessed via our Early Help Toolkit page at: www.kelsi.org.uk/earlyhelp