<p> Children First Hubs Referral Form</p><p>Children First Hubs work with our partners and families when families face difficulties and wish to engage in support. We are committed to the ‘Think Family’ approach and work to ensure we offer the right level of support at the right time. Please consider the questions below and provide as much detail as possible in partnership with the family and young person. </p><p>Details of person making referral</p><p>Name: Contact Details (Tel & Email): Service/Agency: Date of Referral: Has consent been received from the family to share this NO (If no consent given, please provide information? (please tick, date and ensure consent YES (date) reason why?) signatures are noted at the end of this form) Household Address and Contact Number:</p><p>Who lives in the household? (please use additional paper if number of members exceeds below) Child/ Surname Forename DOB Gender Employment Status School Attended Ethnicity Adult Relationships What type of intervention is being requested? (please tick)</p><p>CAF Support Assessment Interventions</p><p>Stay and Play</p><p>Intervention – see our current menu via Early Help Assessment to coordinate Baby Play http://www.wakefield.gov.uk/residents/schools-and-children/early- services and package of support. help/children-first-hubs Book Start</p><p>Preparing for Baby Early Help Assessment in relation to One to One short term support - Parent Carer Needs (Short breaks) Please specify: Parenting Baby Massage Routines Boys Group Boundaries Girls Group Home Conditions Anger Management Practitioner support for lead professional role.</p><p>Please refer to the early help website http://www.wakefield.gov.uk/residents/schools-and-children/early-help/children-first-hubs for further information on interventions. Name and address of family GP (If known)</p><p>Is there a professional assessment in place? If not, why? Is there a My Support Plan in place? Is there a EHCP in place? If yes, please attach most recent documentation to referral e.g. CAF assessment, plan and latest review. PLEASE NOTE we cannot accept a referral without an assessment</p><p>Agencies currently working with the child/family Name Agency Job Role Contact phone & email Lead Practitioner? address (Y/N)</p><p>Families who meet 2 of the indicators below may receive support from the children first hub Please identify at least 2 of the criteria below which are relevant to the family: Evidence Tick Box Evidence of eligibility – who is providing the evidence, what is the evidence and when did it happen? Parents and young people involved in crime or ASB. Consider:  Proven offences in the last 12 months by adults of children  Proven offences in the last 12 months by children or young people  ASB enforcement action</p><p>Children who have not been attending school regularly. Consider:  Persistent absence over at least 3 terms  Multiple school exclusions  Children missing education (CME)  Child attending alternative education provision  If possible, Please provide current school attendance % Children who need help Consider  Child In Need cases  Child Protection cases  Child subject to and Early Help or CAF plan</p><p>Adults out of work or at risk of financial exclusion and young people at risk of worklessness Consider:  Adults on out of work benefits  NEET</p><p>Families affected by domestic violence and abuse Consider:  Police call outs to domestic violence incidents  Family reported incident of domestic abuse in last 12 months</p><p>Parents or children with a range of health problems Consider:  Adult or child with substance misuse issues  Adult or child with mental health problems</p><p>Other Priority Areas: CSE/Missing SEND Young Carers</p><p>CONFIRMATION OF CONSENT FOR INFORMATION TO BE SHARED I understand that information discussed with me will be stored and used for the purpose of providing services to me and my family. I agree that the information recorded can be shared with relevant services that may be able to help, for example: Probation, DWP, Wakefield and District Housing, West Yorkshire Police, NHS, JobCentre Plus, Education.</p><p>Parent/carer signature…………………………………………………………………………Date……………………. Referrer signature……………………………………………Date……………………</p><p>Young person signature (where applicable………………………………………………….…Date……………..... What are the worries/ needs identified? What is working well? What needs to happen</p><p>Family view Family view Family view</p><p>Referrer view Referrer view Referrer view</p><p>What have you already tried?</p><p>Where do you scale the level of concern for the child/ren and family?</p><p>(Significant concerns) 0 1 2 3 4 5 6 7 8 9 10 (no concerns)</p><p>What brings you to this point on the scale today? Please return referrals to the hub address (please ensure you password protect your document or use Cryptshare):</p><p>Castleford, Pontefract & Knottingley Hub – [email protected] Featherstone and South East Hub – [email protected] Normanton and Rural Hub – [email protected] Wakefield Central/North West Hub –[email protected]</p><p>Referrals will not be taken over the phone. For advice on completing the form you can contact the Children First Hubs on: Castleford, Pontefract & Knottingley Hub: 01977 723591 Featherstone and South East Hub: 01977 723165 Normanton and Rural Hub: 01924 307878 Wakefield Central / North West Hub: 01924 303600</p><p>Completed referrals will be considered within 5 working days. Incomplete referrals will be returned to the referrer for completion. Internal use only</p><p>Date referral received</p><p>Internal referral process followed yes/no completed by ______</p><p>Education Improvement Teacher information: </p><p>School attended:</p><p>Professionals involved:</p><p>Other relevant information: </p><p>Outcome</p><p>Incomplete referral, returned to referrer</p><p>Complete, forward to allocation meeting</p>