<p>Parenting project referral form – revised November 2010 Network: Return addresses: A B C Senior Parenting Officer, 2nd Floor, County Hall North, Chart Way, Horsham, RH12 1XA </p><p>2nd Floor, 1st Floor Durban House County Hall North Centenary House South Bersted Buisness Park Chartway, Durrington Lane Bognor Regis, Horsham, West Sussex Worthing West Sussex RH12 1XA BN13 2QB PO22 9RE</p><p>Child’s name ______</p><p>Criteria Sheet:</p><p>The referral must meet the following 5 criteria:</p><p>. Parents have agreed to the referral (and completed sections 6 & 7)</p><p>6). A family child is within the target age range of 10 – 18 years 7) 8). The focus child demonstrates difficulties in two or more settings (mentioned in section 4) and at risk of offending or social exclusion</p><p>. The Risk Assessment section is fully completed including details of pets, risk of harm from aggression or violence, any issues relating to lone working or the layout of the home, other relevant safety information (section 5)</p><p>. The issues are not currently being addressed by another agency or would not be more appropriately addressed by another agency.</p><p>All sections of the referral form must be completed. Sections 6 & 7 must be completed by the parent with the ‘best hopes’ in their words & the service explained to them.</p><p>About the Parenting Project</p><p> The parenting project supports parents with a focus child aged 10 – 18yrs to find effective parenting solutions  Although there are regularly occurring themes like co-parenting, joint problem- solving, boundaries & consequences, relationships and communication we don’t come in as experts offering advice as we recognise that the parents have a better understanding of their own situation  We help them to focus on what is already working & what might work in the future  We work with the parents directly, but not with their children  We offer about six sessions that are free & last about one hour, taking place with the parent at home</p><p>1 Parenting project referral form – revised November 2010 Referral form: Parenting Support (Can be completed on phone particularly if self-referral)</p><p>Date of referral:………………………………………….. Form completed by:……………………………..</p><p>Focus child for the family: Name ………………………………….. Age (DoB) …………………………….</p><p>Gender …………………………………… Ethnicity ……………………………….. Within target range (i.e.10 – 18yrs) 1) The referrer:</p><p>Family referred by: (Please print first and last name)</p><p>Contact details: (if not self-referral) (Full address)</p><p>E-MAIL address: …………………………………………………………………………………………</p><p>Telephone Number ……………………………………………………………………………………….</p><p>Signature of referrer</p><p>2) Information about family:</p><p>First & Last Name(s) of parent(s)/carer: Home address:</p><p>Postcode:</p><p>Telephone/contact details:</p><p>First language:</p><p>Ethnicity of Parents:</p><p>Parents Dates of Birth:</p><p>Is the child a Looked After Child? Yes No</p><p>Details of children in family (with ages):</p><p>Names & Dates of Birth of those living in the household? (Adults and Children)</p><p>2 Parenting project referral form – revised November 2010</p><p>3) Other agency involvement:</p><p>Are any of the following agencies involved?</p><p>YOT Police Social & Caring Services</p><p>CAMHS Educational Psychology Service School nurse</p><p>School Educational Welfare Service CAF</p><p>Sure Start Family Link Worker Team TAC</p><p>Relevant details (including relevant paperwork & outcomes):</p><p>4) Reason for referral:</p><p>Details of the nature of the concern (please include details of any offending behaviour):</p><p>Offending Behaviour (please tick) Yes No </p><p>Where do the child’s difficulties occur? </p><p>(please tick) Please give details:</p><p>School </p><p>Home</p><p>Community</p><p>Elsewhere</p><p>3 Parenting project referral form – revised November 2010 5) Risk Assessment: (Must be completed for referral to be processed)</p><p>Has a professional visited the home? (Include whom & contact details)Yes No</p><p>Has any professional expressed concerns about home visits being carried out? Yes No</p><p>Does the parent have any concerns relating to home visits? Yes No</p><p>Details (Include details of why the answers above were given (both yes & no answers), include details of any pets, the home environment & personal safety</p><p>6) Parent/Carer’s Best Hopes for Receiving Parenting Support:</p><p>What would be the ‘best hopes’ or outcomes that you would like to achieve from working with Parenting Support?</p><p>1.</p><p>2.</p><p>3.</p><p>7) Parent/Carer’s Declaration:</p><p>The referrer has explained to me that:</p><p> The parenting project supports parents to find effective parenting solutions  Although there are regularly occurring themes like co-parenting, joint problem- solving, boundaries & consequences, relationships and communication we don’t come in as experts as we recognise that you have a better understanding of your own situation  We help you to focus on what is already working & what might work in the future  We work with you directly, but not with your children  We offer about six sessions that are free & last about one hour, taking place with you at home</p><p>I certify that the information on this form is accurate to the best of my knowledge.</p><p>Signed: ______Print Name: ______</p><p>4</p>