REQUEST FOR SERVICES FORM

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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.

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 referral been discussed with the parent/carer ?(m) / Yes No
Has the parent given consent to the referral being made?(m) / Yes No
What are the parents/carers views about your concerns and this referral?
Has this referral been discussed with the child/young person? / Yes No NA
What are the child/young person’s views about your concerns and this referral?
If the answer is ‘no’ to any of the above please state reason why. (m)
Is there any information contained in this referral that needs to remain confidential from the child or family? If yes please outline specific information to remain confidential and why.(m)
NB DETAILS OF THE REFERRER TO BE RECORDED BELOW, IF A PROFESSIONAL THEN YOU CANNOT REMAIN CONFIDENTIAL UNLESS THERE ARE EXCEPTIONAL CIRCUMSTANCES
Name of person completing referral(m)
Relationship to child(m)
Date(m) / Tel No.(m)
Email(m)
Address(m)
Date of Referral
Section A - Family Details
Address including Postcode(m)
Main Contact Telephone Number For Parent/Carer (m)
Email Address
Owner/Occupier / Private Landlord / Housing Association / Homeless / Unknown
Children/Young People under 18 living at the above address Please see guidance for completing this section (m – all)
First Name / Surname / DOB / M/F / Age / Eth / Religion / School / 1st Lang / Disability
Adults living at the above address Please see guidance for completing this section (m- all)
First Name / Surname / DOB / M/F / PR/CR / Eth / Religion / Relationship / 1st Lang / Disability
Other relevant people/family members not at the above address (m- all)
First Name / Surname / DOB / M/F / Address including postcode / Eth / Relationship / 1st Lang / Disability
Contact Number
Doctor’s Name:
0-19 Health Service
Professional
Child NHS Number
Services currently involved with family:
Agency / Professional Name / In relation to family member
Please advise which service you are requesting taking in to account the Guide to Integrated Working document (M- ALL)
Statutory Services (Level 4) / Targeted Support (Level 3) / Information Request
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 CSE Screening Tool & CSE 1

Have you asked the family if they would agree to Team Around The Family Support? / Yes No
If you have answered no to this question please explain
Please detail why you are requesting a service and evidence why this meets threshold
(M-ALL)
What do you know about the family, why are you or any other professionals involved?
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 as above)

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
Are there any potential risks that would affect Staff visiting the home?

Please email the completed form to:

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