Referral Form - MESH s3

Scheme Use: Family No: Date referral received: Referral Meeting Date: Not Allocated Allocated Not Supported Destruction Date: Project: Input Date, System & Initials Input Date, System & Initials

HOME-START BRADFORD DISTRICT The Thornbury Centre, Leeds Old Road, Bradford, BD3 8JX, Tel: 01274 666711, Fax: 01274 665860, Email: [email protected], Website: www.homestartbradford.co.uk

REFERRAL FORM o Please note all referrals must be made with the consent of the family. Have you discussed this with the family prior to completing this form? YES / NO o The family must have at least one child under the age of five years. o We are unable to process your referral until we have received this form completed in full

Surname of Main Carer …………………………...... Email ……………………………………………………………………… Address…………………………………………………………………………………………………………… Postcode …………………………………………..…………………….. Tel. No …………………………...... Mobile No …………………..………...... Please provide all details about the adults and child[ren] Please note the family must have at least one child under the age of 5 years

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FORENAME SURNAME BIRTH S Mother/ Y Y Y Y Y Y/N Y/N Y Y Partner N N N N N N N Father/ Y Y Y Y Y Y/N Y/N Y Y Partner N N N N N N N Home-Start Bradford District Referral Form (6 pages) 4/17 1 Other Main Y Y Y Y Y Y/N Y/N Y Y carer(s) N N N N N N N Other Main Y Y Y Y Y Y/N Y/N Y Y carer(s) N N N N N N N

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FORENAME SURNAME BIRTH C C1 Y Y Y Y Y/N Y/N Y Y N N N N N N C2 Y Y Y Y Y/N Y/N Y Y N N N N N N C3 Y Y Y Y Y/N Y/N Y Y N N N N N N C4 Y Y Y Y Y/N Y/N Y Y N N N N N N C5 Y Y Y Y Y/N Y/N Y Y N N N N N N C6 Y Y Y Y Y/N Y/N Y Y N N N N N N C7 Y Y Y Y Y/N Y/N Y Y N N N N N N C8 Y Y Y Y Y/N Y/N Y Y N N N N N N

Ethnicity Key: Asian or Asian British Black or Black British Mixed White Other A1 Indian B1 Caribbean M1 Mxd White & Bk Carribbean W1 British W5 Romanian O1 Chinese

Home-Start Bradford District Referral Form (6 pages) 4/17 2 A2 Pakistani B2 African M2 Mxd White & Blk African W2 Irish W6 Czech O2 Arab A3 Banglasdeshi B3 Other M3 Mxd White & Asian W3 Polish W7 Other WhiteO3 Any Other ethnic background A4 Other Asian M4 Other Mxd / multiple W4 Slovakian O4 Prefer not to say

Referred by: Date of referral: Name Family Doctor Role Tel Agency Health Visitor Address Tel Postcode E mail All other agencies involved (if none please state none) Tel E mail

Substance Lone parent Mental health Domestic Postnatal Learning Teenage Physical Speech Smoker Other please misuse issues abuse depression disability pregnancy disability Language specify (19yrs or younger) YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO

Interpreter required Yes/No (please note we cannot always provide this service) Basic English Spoken YES / NO

Languages Spoken (please tick all relevant) (*Bengali includes Sylheti, Chatgaya, Chittagonian)

Arabic Bengali * Gujarati Hungarian Pashto Polish Punjabi Romanian Russian Spanish Slovakian Urdu Other (please specify):

Please add any background information that you think we would find useful (if necessary attach an extra sheet)………………………………………………………………… …………………………......

…..………………………………………………………………………………………………………………………...... ………………………………………………………………………………………………………………………………………………………………………………………………………………. ………………………………………………………………………………………………………………………………………………………………………………………………………………. ………………………………………………………………………………………………………………………………………………………………………………………………………………. Are there any Health and Safety issues that we need to consider when placing a volunteer with this family: (eg pets, access to property, etc) YES/NO (if yes please give further information) …………………………………………………………………………………………………………………………...... Home-Start Bradford District Referral Form (6 pages) 4/17 3 ……………………………………………………………………………………………………………………………………………………………………………………………………………….

Home-Start Bradford District Referral Form (6 pages) 4/17 4 Family needs - So that we can offer the family the most appropriate support, and match the most suitable volunteer, please complete the following table. Families will not be prio ritised 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.

Family Needs - the questions may help you to identify the family’s needs, Yes or though we appreciate there may be other areas the family would like support No Please tell us why this is a need and the impact on the child with PARENTING SKILLS 1. Managing child’s behaviour Are there any behavioural issues with the children? Would the family like support around routines and boundaries? (including what is normal behaviour) Would the family like information about parenting programmes to help manage the children’s behaviour? 2. Being involved in the child(ren)’s development Do the children have opportunities to be creative, explore, experiment; interact with others? Would you like support around play, reading, singing, homework, talking, etc? Would you like information about early learning & childcare services? Have the children seen the health visitor for 2-2.5 year development check? PARENT’S WELL BEING 3. Coping with own physical health Any ongoing physical illness/disability? Are they eating/sleeping well? Would the parents/carers like to increase their level of physical activity? Would the family like support to use outdoor spaces for exercise? e.g. walking, going to the park & playing ball games with the children Would they like to cease/reduce alcohol, drugs or tobacco use? 4. Coping with own mental health Any ongoing mental health issues? ie depression, anxiety, panic attacks etc How does the parent/carer look after their emotional wellbeing? Would they like support to access services around your emotional wellbeing? 5. Coping with feeling isolated Does the parent/carer feel isolated? Do they want support to reduce their isolation? What kinds of things would they like to do? 6. Parent’s self esteem How does the parent/carer feel about themselves? Do they feel confident in their own self worth and abilities? Would they like support to build your confidence? Family Needs - the questions may help you to identify the family’s needs, Yes though we appreciate there may be other areas the family would like support or No Please tell us why this is a need and the impact on the child with Home-Start Bradford District Referral Form (6 pages) 4/17 5 CHILDREN’S WELL-BEING 7. Coping with child’s physical health Any ongoing illness/disability? Are the children up to date with their vaccinations/immunisations? Do the children eat/sleep well? Would the family like support around healthy foods, meals etc? (focus on children) Do the children have opportunity for physical play? 8. Coping with child’s mental health Are the children are happy? Do they interact with other people? Are they confident? Do they have positive friendships at school? Is there any bullying? Is there anything happening in the family’s life that might affect the children’s wellbeing? FAMILY MANAGEMENT 9. Managing the household budget Is the family in receipt of benefits/tax credits etc? Would they like benefits advice? Would they like support with forms, budgeting, shopping etc? Would they like support around budgeting/shopping for healthier lifestyle choices for your whole family? Would they like help to reduce fuel bills? 10. The day-to-day running of the home Can the parents/carers manage the house work etc? Would they like help with routines? ie meal/bed times etc? Would they like information about safety around home? Would they like information and advice about safety equipment, accident prevention, road safety, internet safety, car seats? 11. Stress caused by conflict in the family Is any member of the family suffering domestic violence? Do they want to access a domestic violence support service? Is there any other stress/conflict in the family?

How is this affecting the children?

Home-Start Bradford District Referral Form (6 pages) 4/17 6 Family Needs - the questions may help you to identify the family’s needs, Yes though we appreciate there may be other areas the family would like support or No Please tell us why this is a need and the impact on the child with 12. Coping with multiple birth/multiple children under 5 Is there more than 1 child under 5? Does the family manage to get out with the children? Would they like help with the extra work? 13. Use of Services Are there any other agencies/services involved with the family? Would the family like support to use health & wellbeing services (not exercise) i.e. dentist, GP, optician; immunisations, developmental checks, hospital appointments

Would they like support to access maternity services? Do they want support to access services to help them reduce/stop drugs, alcohol or tobacco, including during pregnancy/after the baby is born? Are there any other services they would like to use? 14. Other (please describe) Would the family like information around the benefits of breastfeeding? Would they like support in making the choice to breastfeed?

Would they like information about oral health including:  Preventing dental decay in children  using feeding cups rather than bottles at weaning  reducing drinks that are high in sugar  improving the oral health of the family

Has the family received support from Home-Start Bradford District previously? YES/NO If yes, when did Home-Start support end? Date ......

Referrer’s signature ……………………………………….. Date ………………………………… Thank you for taking time to provide this information which will help us to process the referral. 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 Melanie Roberts-Saunders, Scheme Manager 01274 666 711

FOR CONFIDENTIALITY PURPOSES PLEASE DO NOT EMAIL THIS FORM WHEN COMPLETED

Home-Start Bradford District Referral Form (6 pages) 4/17 7