Referral Form - MESH s1

Blackbird Leys Youth and Community Centre, Blackbird Leys Road, Oxford OX4 6HW T 01865 779991 E [email protected] W home-startoxford.org.uk

Home-Start Oxford Referral Form Scheme Use

Family Name: Date Received: Family No.:

Address:

Contact No. Tel: Email: Mobile:

Please provide details about the adults caring for the child[ren]:

Name Main Resident in Relationship to child/ren if applicable carer √ household√ Mother/partner Father/partner Other main carer[s] Other main carer[s]

Referrers Details Name: Date of Referral: Role: Family Doctor: Agency Tel no: Address: Health Visitor Email: Tel: Tel No. Email: Mobile No. Other Agencies involved: Please ‘X’ all that apply to this family

n d . s y

t e s y e t e e e o Other Please specify i i i h t r r l t i s s t u n i i i l s y r l i s u u i e i u b s r b s s b 9 q b B a i i e a a r a 1 a e s i

s p r e h m p s i r l

i c l r D i e p e e

e t D d i a e

d t d n c s t t d l e l l l g i n o e n e u h u a r n h u L a i t l

t m d p M n a C r y a s o r A t n c e b d a - t n t n u e n e l s a s I o n m p g e r p

e g a n e e T

Are there any Health and Safety issues regards to lone working & home visiting this family: Y/N

Have you visited the family home Y/N Please add any background information that you think we would find useful (if necessary attach an extra sheet

1 2 Details of Children

N.B. PLEASE COMPLETE ALL SECTIONS - WE are unable to process this referral without all of the information.

√ l n

C Child’s name H a a ? c l i A S r n h h n

Eldest first T P e E o / s r s i s h i i t t n t F s a M u i i t ( r s c o r E A i

a h t e B s r t B t T f n

c r i s d e i r o n k e a r p e h e b t d e c n a t

t i p e u f i d e o m a

o r s l i O o x n o h N t d i r y

P A B r e f a a

e b W M r o G r r t

o e d G

l l g o o a d i t

e h n e D s k l n m e h c e C b a t i

m a n a l m i I s s s i s h i B A

s d C o

e h e s b

r r W c

e e n e h h e e g d i l l t d n e e A i s s s o e n a e

n i i a t a i k a e h t c r h e x g t e i i h i I d e e e r t r M m r n d u i f n f O e b n W a m e e E B

h s e i e r b A r i F n C r y n i h e r

P C e i R

l e n a s m a d i h n i d a h t l e i A u n s t i a l s C t c d a O y h A n i O s

o a i s l o r d C k S g A e n

C I a n h o ? t t P a

t O O B c N / e j S b E u Y S

C.1 C.2 C.3 C.4 C.5 C.6 C.7 C.8 C.9 C.10 C.11 C.12 C.13

Please complete those boxes which apply to any of the children. Note the terms above are nation-specific – not all will be relevant in your area.

3 Family needs - So that we can offer the family the most appropriate support, and match the most suitable volunteer, please complete the following table. Please note that there is not a ‘points’ system. Families will not be prioritised on the basis of how many categories are ticked. This information, together with information provided by the family, will be used to monitor how our support meets the family’s needs. I hope that Home-Start will help meet needs the family has in the following areas:

Family needs X If you have ticked, please tell us why this is a need

Managing child’s behaviour

Being involved in the child(ren)’s development

Coping with own physical health

Coping with own mental health

Coping with feeling isolated

Parent’s self-esteem

Coping with child’s physical health

Coping with child’s mental health

Managing the household budget

The day-to-day running of the house

Stress caused by conflict in the family

Coping with multiple birth/multiple children under 5

Use of services

Other (please describe)

4 Details of other members of the household with responsibilities for caring for the children

N.B. PLEASE COMPLETE ALL SECTIONS - WE are unable to process this referral without all of the information. c o i t h h

n s s s s i i h t t t u e i i t r v r E l a

h d t B B r t e

r e s e r s i l

n k p h e d e b b n a c t m t

i u e d i a f a o e s l i O x o n s h o

t i i h r

A B r e t a

e W M G r o

r r t r G

e g o o a e e i

b d D s k n i m e c a s i n a m n i l I s o h B A C C i i

r r c e e g n n n e h e e ? d h i l l n h t n e e s s s i a e n a a e S s n i i i i a i a a k a h t t c r h e x g t i s i h e i d I d E e e s t r M m r n u i d i n n f f A O e b Y W m I e E B k h a s e e b A r l r

i F a r y r P e C g e R e n P m a h n h t h t u A t a l C O O y B O s A

Main Carer

Partner living in household

Referrers Signature: Date

Parents Signature: Date:

I have discussed with the family and they have agreed to this referral. (please mark an X in the box) Date:

Thank you for taking time to provide this information which will help us to process the referral. We are unable to process your referral until we have received this form We will try to respond to you within two weeks to tell you about progress with this referral. We will remain in touch while supporting this family and will contact you when the support ends If you have any issues or concerns about the referral process or the support for the family please contact [email protected]

Office Use Only

Discussed at Referral Meeting Date: Family Co-ordinator ABC/KC/KP Date: Other (please specify) Date:

Unplanned Ending Inappropriate Referral Out of Area No Co-ordinator Capacity No ISO Capacity No volunteer Capacity Date: