Office use only Family ID: East Cumbria Family Support Association Referral Form for all ECFSA Services
CHILD/YOUNG PERSON’S DETAILS Surname ______First Names ______Date of Birth ______Gender ______Address ______Postcode ______Tel ______Mobile phone ______Email ______Religion ______Ethnicity ______1st language/preferred means of communication ______Is an interpreter/signer required? Yes / No Special needs? Yes / No If yes, nature of special needs ______Name of nursery/school ______Address ______Tel ______
PRINCIPAL CARERS Surname First name DOB optional Relationship to child/young person Parental responsibility Yes / No Yes / No
OTHER HOUSEHOLD MEMBERS Surname First name Relationship to Date of birth Name of school if a child Child/young person
ASSESSMENT OF THE CHILD/YOUNG PERSONS NEEDS AND CIRCUMSTANCES If an Early Help Assessment or Initial Assessment has been carried out, a copy of this should be attached and you may then go straight to the reason for referral section. Please include any historical information which is appropriate to share and would help us to support this family. If the referral is for Group Support please go straight to reason for referral section.
Child/Young Persons Developmental Needs
Please record information you have in relation to the child/young persons developmental needs, both areas of strength and need.
HEALTH – including physical, social, emotional and behavioural development
EDUCATION-
Revised April 2017 Page 1 of 6 IDENTITY, SELF IMAGE, SELF ESTEEM AND SOCIAL PRESENTATION
FAMILY AND SOCIAL RELATIONSHIP
SELF CARE SKILLS
Parents/carers capacity to respond appropriately to the child/young persons needs
Please record both areas of strength and need.
BASIC CARE, ENSURING SAFETY AND PROTECTION
EMOTIONAL WARMTH AND STABILITY
STIMULATION, GUIDANCE AND BOUNDARIES
Family and environmental factors which may impact on the child and family
FAMILY HISTORY, FUNCTIONING AND WELL BEING
SOCIAL RESOURCES AND SUPPORTS
HOUSING, EMPLOYMENT AND INCOME
Revised April 2017 Page 2 of 6 REASON FOR REFERRAL
Identified needs Seriousness Service requested Expected outcome This should (What will happen if no be discussed with the child intervention?) and/or main carer
KEY AGENCIES (please record all agencies that you know are working with the child/family including both voluntary and statutory)
Name ______Name ______Address ______Address ______Postcode ______Postcode ______Tel ______Tel ______Email ______Email ______(Please continue overleaf if necessary)
Referred by ______Date ______Agency/relationship to child/young person ______Address ______Tel ______Email ______
Referrer’s signature ______Date ______
PARENTAL CONSENT I agree with the information on this form being shared with East Cumbria Family Support Association to help me meet the needs of my child
Signature of Parent/main carer……………………………………Name of Parent/carer……………..………………
Date ……………………………………………………….
Revised April 2017 Page 3 of 6 EAST CUMBRIA FAMILY SUPPORT ASSOCIATION RISK ASSESSMENT
This form is to enable the Association staff to plan and provide a service which is safe for staff, volunteers and other service users. FAMILY NAME: ______Family ID: ______ADULTS YES NO Does any adult closely connected to the family (including ex-partners) have any convictions that the Association should be aware of eg identified as presenting a risk, or potential risk, to children, convictions for violence? If yes please give details
Does any adult closely connected to the family (including ex-partners) have any known aggressive, violent or intimidating behaviour including domestic violence, either now or in the past? If yes please give details
Are there any mental or physical health conditions that would need particular care and attention or safe practice? If yes please give details
CHILD/CHILDREN YES NO Do any of the children have any presenting behaviours which could cause a risk to themselves/other children/adults? If yes please give details
Do any of the children have any emotional or physical health conditions that would need particular care and attention, or safe practice eg temper tantrums, epilepsy, diabetes? If yes please give details
Are there any risk and management plans in operation, eg time out, medication? If yes please give details
ENVIRONMENT YES NO Are there any hazards in the home/garden which might affect the safety of workers and volunteers, eg animals, substances, waste? If yes please give details
Revised April 2017 Page 4 of 6 NAME OF PERSON COMPLETING FORM ______AGENCY ______
Signature: ______Date: ______
Revised April 2017 Page 5 of 6 FOR OFFICE USE ONLY
SECTION BELOW TO BE COMPLETED BY ECFSA WITH THE FAMILY
INFORMATION SHARING
When supporting families ECFSA needs to keep records of their involvement. The organisation works closely and share information with other agencies including Health, Education, Children’s Social Care and any other relevant voluntary and community groups.
I understand the information that is recorded on this form and that it will be stored and used for the purpose of providing services to:
Me Child or young person for whom I am the parent Child or young person for whom I am the carer
I have had the reasons for information sharing explained to me and understand those reasons.
I agree to the sharing of information: (please tick)
As an organisation we do not tolerate any violent or aggressive behaviour towards members of staff or volunteers.
I understand and agree with this statement: (please tick)
During you and your child’s involvement with East Cumbria Family Support Association (ECFSA) there may be occasions when a photograph or moving image will be taken. We may include these photographs in an annual report, for publicity or evaluation purposes, or to show to our funders.
All photographs/moving images will be stored in a secure place
I agree that photographs of my child/children taken by ECFSA can be used for the above purposes: (please tick)
Signed:...... Date: ...... (Parent/Main Carer)
Signed:...... Date: ...... (On behalf of East Cumbria Family Support)
Please return completed signed form and completed risk assessment to:
Eden area: Sarah Craig, Family Support Coordinator, East Cumbria Family Support Association, The Office, Mardale Road, Penrith CA11 9EH Tel: 01768 593102
Carlisle area: Dan Nicholson, Family Support Coordinator, East Cumbria Family Support Association, At Carlisle West Children’s Centre, Wigton Road, Carlisle, CA2 6JP Tel: 01228 227348
Revised April 2017 Page 6 of 6