Screening questions to answer before making a referral
Please delete highlighted sections as appropriate on Page 1.
The blank referral form begins on page 3 of this document
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1. Does this referral involve at least one child under the age of 12? Yes ☐ No ☐
Safe Families for Children will work with older children, but only as part of a sibling group. If there is no child under the age of 12, there is the possibility that Safe Families for Children will still take the case as a ‘wild card’ so it is worth asking by phone or email prior to filling out a referral form.
2. Without Safe Families for Children’s support, are one or more children in the family on a downwards trajectory towards needing accommodating? Yes ☐ No ☐
3. Does the lead parent/carer have parental responsibility?Yes ☐ No ☐
4. What level of risk is associated with Safe Families for Children staff or volunteers regularly visiting the home? High ☐ Medium ☐ Low ☐
Please use your professional judgment and consider the fact that Safe Families is a volunteer-driven intervention. You will be able to detail specific risks in the referral form. Unfortunately, Safe Families is unable to work with ‘high’ risk families.
5. What level of risk do the family members present to Safe Families for Children staff or volunteers? High ☐ Medium ☐ Low ☐
Please use your professional judgment and consider the fact that Safe Families is a volunteer-driven intervention. You will be able to detail specific risks in the referral form. Unfortunately, Safe Families is unable to work with ‘high’ risk families.Please consider all family members.
6. Do you agree (on behalf of your local authority) to the terms and conditions of Safe Families for Children? Yes ☐ No ☐
Full Terms & Conditions are listed on the following page.
7. Is the lead parent/carer contact aware of the referral, clear about the support that Safe Families for Children offer and agree to a home visit within 2 working days? Yes ☐ No ☐
Please ensure voluntary consent is given by the parent/carer.
Safe Families for Children - Terms and conditions
Top of Form
  • Safe Families will respond to a referral with a home visit to the referred family, therefore it is essential all relevant support and risk information is provided accurately.
  • Safe Families office hours are 9am to 5pm Monday to Friday. Staff are available to support referred families and volunteers outside of these times, however, referrals will only be received and reviewed during the core office hours.
  • Any referral with a requirement for support to begin within 24 hours should also be followed up with a telephone call to highlight the urgency. This will assist in progressing support at the earliest opportunity and contact details for your local office may be found on our website -
  • In certain circumstances Safe Families may be unable to support a referred family following the initial home visit. In such instances this will not be counted towards the number of referrals agreed with a Local Authority unless the decision to not provide support is made on the basis of information omitted from the referral, which could/should have been provided.
  • Requests for urgent support may require the referrer to complete relevant consent forms with the family on behalf of Safe Families prior to the support commencing. This applies particularly to referred cases that do not allow sufficient time for a home visit. The forms, or a copy of, must be received by Safe Families before support can commence.
  • Where overnight hosting is requested and school runs are required, the referrer will retain responsibility for the provision and cost of school runs. Safe Families will notify the referrer in the event of school run provision being offered or available via volunteer support.
  • In instances of referred families being unable to communicate in English, Safe Families will endeavour to identify a volunteer with suitable language skills. In such instances it may not always be possible to fulfill an initial home visit within 2 working days.
  • Where overnight hosting is the only support type required, i.e. no befriending, and there is no significant language barrier with the children, Safe Families will identify a volunteer with suitable language skills to act as an interpreter with the parents of the referred family during the home visit. Where this is not possible it will be the responsibility of the referrer to provide an interpreter during the initial home visit, allowing hosting support to be agreed.
  • Instances of befriending support will only be practical where a volunteer with suitable language skills can be identified.
Incoming Referral Form
Please return to .
Forms sent to will be forwarded to Together for Children.
You may password protect this document prior to sending if you have security concerns.
Pre-referral enquiries may be made to Together for Children on: 0191 561 4084 or to Safe Families for Children on: 0191 7070033
Date: / Family ID (Safe Families only):
Main Parent/Carer Details
Full Name / Address / D.O.B. / Gender
M/F / Ethnicity / Relationship to Main Parent/Carer / Has PR?
☐ /
Other Adults in Household:
if different from above / ☐ /
Children:
if different from above
Parent/Carer additional information
Has consent been gained from Main Parent/Carer for the referral? ☐
Tel No: / Mobile(s):
Language spoken: / Is an interpreter required? ☐
Religion (incl. none): / Asylum Seeker? ☐
Local Authority:Sunderland
Is this referral being considered as part of an Early Help Plan? Yes/No
If not, why is this?
Information should not be shared with?
Referrer details (leave blank if self-referral)
Name: / Role:
Agency/Organisation:
Address/Base:
Contact number(s):
Email address:
Reason for referral (please give details below):
Please indicate the support required
Overnight hosting required for: child/children ☐ to include parent/carer? ☐
How urgent is hosting to begin:
24 hrs ☐ 48 hrs ☐ up to 1 week ☐ 1 to 2 weeks ☐ 2 weeks or more ☐
Expected duration of hosting:
1 – 3 nights☐ 4 – 7 nights☐ 8 – 14nights☐ Instances of hosting: Single ☐ Multiple ☐
Befriending required for: child/children ☐ parent/carer ☐
How urgent is befriending to begin:
up to 1 week ☐ 1 to 2 weeks ☐ 2 weeks or more ☒
Expected duration of befriending:
less than 1 month ☐1 – 3 months ☐ 3 – 6 months ☐
Statutory Involvement
Are other agencies/professionals involved in supporting the family? Yes ☐ No ☐
If yes please provide details:
What is the current level of pre-social care or Social Care involvement? please select all relevant options
Early Help: ☐ CiN: ☐ CP: ☐ Court/PLO: ☐
Other (please provide details):______
What was the previous level of pre-social care or Social Care involvement? please select all relevant options
None: ☐ Early Help: ☐ CiN: ☐ CP: ☐ Court/PLO: ☐ LAC: ☐
Other (please provide details): ______
Risk Assessment:
Please select below any known risks impacting parent/carer/child
Risk Factors / Child / Parent/
Carer / Others in household
Substance misuse / ☐ / ☐ / ☐
If selected above, please provide details:
Mental health(incl. self-harm) / ☐ / ☐ / ☐
If selected above, please provide details:
Additional health issues: (i.e. allergies) / ☐ / ☐ / ☐
If selected above, please provide details:
Physical / Learning disabilities / difficulties / ☐ / ☐ / ☐
If selected above, please provide details:
Domestic Violence / ☐ / ☐ / ☐
If selected above, please provide details:
Behavioural issuesi.e. verbal, physical, criminal / ☐ / ☐ / ☐
If selected above, please provide details:
Abuse i.e. sexual, neglect, emotional, physical / ☐ / ☐ / ☐
If selected above, please provide details:
Otheri.e. issues around false allegations / ☐ / ☐ / ☐
If selected above, please provide details:
Please highlight any risks with respect to the home environment
Is it safe to undertake a home visit? Yes ☐ No ☐
If noto above, please provide details of personal & environmental risks below:
Are there any known restrictions on contact betweenfamilymembers or others, Yes ☐ No ☐
including areas where people live? If yes please provide details:
Are there any relationship problems or history of family conflict? Yes ☐ No ☐
If yes please provide details:
Our volunteers are mainly Christian and come from a variety of backgrounds, races and cultures. Is there any reason this would be of concern for the parent/carer or child/children? Yes ☐ No ☐
If yes please provide details:

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Referral Form 2017 for use in Sunderland only

Safe Families for Children is a Registered Charity No 1150405 and Company Limited by Guarantee Registered in England and Wales No 8134971. The Registered Office is 5 Diamond Court, Newcastle upon Tyne, NE3 2EN.