Single Agency Referral Form

This form is to be used when making a referral into Children’s Social Care, or for a referral to a single agency or for Early Help. The form should be completed with consent unless the referral is due to child protection concerns and to approach the child/young person/parent/carer would mean an increased risk of significant harm, prejudice the prevention or detection of crime, or place an adult at risk of significant harm.

Date of Referral: Click here to enter a date.

Agency Referred To: Choose an item.

If ‘other’ please specify: Section 1: Referrer’s Details Name & Designation:

Address:

Telephone: Email:

Section 2: Child/Young Person’s Details Name:

Gender: Choose an item.

Date of Birth: Click here to enter a date.

Address: Telephone

Language Choose an item.

Ethnicity Choose an item. Religion Choose an item.

Parent/Carer’s first language Does the child have an identified Special Choose an item. Educational Need? If yes, which are the main areas of need? Choose an item. Education & Health Care Plan? Choose an item.

If yes, please provide details.

Do you consider the child to have a disability, as Choose an item. defined by the Equality Act 2010? Section 3: Reason For Referral Details:

What work has already been completed to support this child and/or family? SARF V15 What are your service and the child/family expecting from this referral?

Section 4: Details of parents/carers and family Name: Relationship:

Address (if different)

Telephone: Parental Responsibility: Choose an item.

Please list below any other children or adults within this family/household

Name- DOB/Age Relationship

Section 5: Services working with this child and/or family Please list below any agencies working with this family (eg GP, Health Visitor, School)

Section 6: Risk Assessments Are there any known risks if a home visit was to be Choose an item. carried out?

If yes, please provide details.

Section 9: Supporting Documents Are you providing any documents or separate information to support this referral? If yes, please provide details.

Section 10: Consent Is the parent/carer aware of this referral? Choose an item. If not, please detail why this referral is being made without consent Is the child/young person aware of this referral? Choose an item. Comments of parent/carer and or child/young person

In submitting this form, I confirm that I have obtained consent, as appropriate, and that the parent/carer and/or child understand that information will be shared (as appropriate) between relevant professionals including the Trafford Care Coordination Centre.

SARF V15