<p> REQUEST FOR SERVICES FORM ______</p><p>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.</p><p>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?</p><p>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?</p><p>If the answer is ‘no’ to any of the above please state reason why. (m)</p><p>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)</p><p>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)</p><p>1 Date of Request</p><p>Section A - Family Details Address including Postcode (m)</p><p>Main Contact Telephone Number For Parent/Carer (m) Email Address Housing Owner/Occupie Private Associatio Homeless Unknown r Landlord n</p><p>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)</p><p>M/ 1st First Name Surname DOB Age Eth Religion School Disability F Lang</p><p>Adults living at the above address Please see guidance for completing this section https://www.wirralsafeguarding.co.uk/multi-agency-thresholds/ (m- all)</p><p>1st First Name Surname DOB M/F PR/CR Eth Religion Relationship Disability Lang</p><p>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</p><p>Contact Number Doctor’s Name: 0-19 Health Service Professional Child NHS Number </p><p>2 Services currently involved with family: Agency Professional Name In relation to family member</p><p>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?</p><p>If you have answered no to this question please explain </p><p>Please detail why you are requesting a service and evidence why this meets threshold https://www.wirralsafeguarding.co.uk/multi-agency-thresholds/ (M-ALL)</p><p>What do you know about the family, why are you or any other professionals involved?</p><p>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/</p><p>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</p><p>Are there any potential risks that would affect Staff visiting the home? </p><p>Please email the completed form to: [email protected]</p><p>4</p>