Multi-Agency Referral Form

REQUEST FOR SERVICES FORM ______

This form is to be used to access services for Children and Families at levels 3 and 4 of the continuum of need and requests for information.

IN THE EVENT OF IMMEDIATE SAFEGUARDING RISK PLEASE CONTACT Monday – Friday - 9am – 5pm 0151 606 2008 Outside of these hours: 0151 677 6557 Questions marked as (m) are mandatory and require completion CONSENT AND CONFIDENTIALITY (NB when seeking consent please ensure that parents/carers understand that the information will be shared with services where considered appropriate to do so) Has this request been discussed with the parent/carer ? (m) Yes No Has the parent given consent to the request being made? (m) Yes No What are the parents/carers views about your concerns and this request?

Has this request been discussed with the child/young person? Yes No NA What are the child/young person’s views about your concerns and this request?

If the answer is ‘no’ to any of the above please state reason why. (m)

Is there any information contained in this refquest that needs to remain confidential from the child or family? If yes please outline specific information to remain confidential and why. (m)

NB DETAILS OF THE PERSON COMPLETING THE FORM TO BE RECORDED BELOW, IF A PROFESSIONAL THEN YOU CANNOT REMAIN CONFIDENTIAL UNLESS THERE ARE EXCEPTIONAL CIRCUMSTANCES Name of person completing request (m) Relationship to child (m) Date (m) Tel No. (m) Email (m) Address (m)

1 Date of Request

Section A - Family Details Address including Postcode (m)

Main Contact Telephone Number For Parent/Carer (m) Email Address Housing Owner/Occupie Private Associatio Homeless Unknown r Landlord n

Children/Young People under 18 living at the above address Please see guidance for completing this section https://www.wirralsafeguarding.co.uk/multi-agency-thresholds/ (m – all)

M/ 1st First Name Surname DOB Age Eth Religion School Disability F Lang

Adults living at the above address Please see guidance for completing this section https://www.wirralsafeguarding.co.uk/multi-agency-thresholds/ (m- all)

1st First Name Surname DOB M/F PR/CR Eth Religion Relationship Disability Lang

Other relevant people/family members not at the above address (m- all) Address M Eth 1st First Name Surname DOB including Relationship Disability /F Lang postcode

Contact Number Doctor’s Name: 0-19 Health Service Professional Child NHS Number

2 Services currently involved with family: Agency Professional Name In relation to family member

Please advise which service you are requesting taking in to account the Guide to Integrated Working document https://www.wirralsafeguarding.co.uk/multi-agency-thresholds/ (M- ALL) Statutory Services Targeted Support Information Request (Level 4) (Level 3) Is there a risk of immediate harm? Yes No If Yes Please Contact – 0151 606 2008 CSE Indicators Yes No If you have answered yes complete the CSE Screening Tool & attach https://www.wirralsafeguarding.co.uk/tools-for-professionals/ Have you asked the family if they would agree to Yes No Team Around The Family Support?

If you have answered no to this question please explain

Please detail why you are requesting a service and evidence why this meets threshold https://www.wirralsafeguarding.co.uk/multi-agency-thresholds/ (M-ALL)

What do you know about the family, why are you or any other professionals involved?

3 Please describe what is working well and what work has been undertaken by your agency to assist this child/family? (Please attach any assessment reports/documents completed e.g DASH/RIC, CSE TOOLS, Graded Care Profile etc) https://www.wirralsafeguarding.co.uk/tools-for-professionals/

Please detail any special needs or circumstances of any family member, which may affect this referral or communication and understanding between the family and professional agencies

Are there any potential risks that would affect Staff visiting the home?

Please email the completed form to: [email protected]