<p> Single Agency Referral Form</p><p>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.</p><p>Date of Referral: Click here to enter a date.</p><p>Agency Referred To: Choose an item.</p><p>If ‘other’ please specify: Section 1: Referrer’s Details Name & Designation:</p><p>Address: </p><p>Telephone: Email: </p><p>Section 2: Child/Young Person’s Details Name:</p><p>Gender: Choose an item.</p><p>Date of Birth: Click here to enter a date.</p><p>Address: Telephone</p><p>Language Choose an item.</p><p>Ethnicity Choose an item. Religion Choose an item.</p><p>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.</p><p>If yes, please provide details.</p><p>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: </p><p>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? </p><p>Section 4: Details of parents/carers and family Name: Relationship:</p><p>Address (if different) </p><p>Name: </p><p>Telephone: Parental Responsibility: Choose an item.</p><p>Please list below any other children or adults within this family/household</p><p>Name- DOB/Age Relationship</p><p>Section 5: Services working with this child and/or family Please list below any agencies working with this family (eg GP, Health Visitor, School)</p><p>Section 6: Risk Assessments Are there any known risks if a home visit was to be Choose an item. carried out? </p><p>If yes, please provide details. </p><p>Section 9: Supporting Documents Are you providing any documents or separate information to support this referral? If yes, please provide details.</p><p>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</p><p>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.</p><p>SARF V15</p>