EssexRequestforSupportFormand Consent

Pleasetick anyissuesyoubelievearepresent inthefamily. Evidencetosupport issues identifiedwill berequiredfurther in this form. Please remember that the level of need should be deemed as 'Intensive'. Tocheck this, please refer to page 19 of the Effective Support for Children and Families in Essex Guidance.
For Family Solutions to work with a family they need to have two or more of the following difficulties. Please tick all those that apply:
Families with no member in work
Families with significant non-school attendance (for whatever reason)
Families with members involved in crime or anti-social behaviour
Families affected by domestic violence
Families living with drug and alcohol misuse
Families where children are in need and open to social care
Families where children exhibit significant behavioural difficulties
Families facing eviction or with significant rent arrears or neighbour disputes
Families with one or more member of the household with (tier 2) mental health needs
Other (please specify)

If you would liketo discuss the request prior to submission please telephone 0845 603 7627 and ask for the Early Helpand Advice Hub. The Hub can also provide information, advice and guidance to you.

Please submit this request to:

Early Help and Advice Hub

Essex House

200 The Crescent

Colchester Business Park

Colchester

CO4 9YQ

Email: or

Privacy Notice - For full details on how Essex County Council – Family Solutions service process your personal information, visit:

Section 1to be completed by the Family

Section 2 to be completed by the person helping to complete this form (Section 3 if required)

Section 4 to be completed together

Section 5to be completed together

Section 6to be left with the FamilyECC11238

Section 1:Family ConsenttoShareInformation
Thissection should becompletedbya family memberwith parental responsibility. Forindividualrequeststhissectionmust be completed bya personoverthe age of13.
Please readcarefully,completethe restrictionbox ifappropriate,thensignand datetheform.Ifyou haveconcerns pleasediscussthemwiththepersonworkingwith you.
Iagreethat personalinformation aboutme/my/ourchild(ren)maybeshared with orrequestedfromother agenciesand with other professionals,sothatmyfamily’sneedscan beassessed, orI/my/ourchild(ren) can be provided with services.
Iagreethat personalinformation aboutme/mychild(ren)maybe sharedwith orrequestedfrom other professionals,sothatI/my/ourchild(ren)canbe provided with servicesand evidence the effectivenessof involvementboth during and post involvement.
IunderstandthatI have the righttorestrictwhatinformationmaybe shared and with whom.
IunderstandthatImaywithdrawmyconsenttoshare information atanytime andthismayresultin a reduction ofservicesbeing available.
Information I do not want to be shared:
Name ofMain Family Contact / Date:
Signature of Main Family Contact
Contact Numbers
Family Address:
Postcode:
EmailAddress:
IMPORTANT:The main family contact needs to sign besideany member of the Family that is aged 15 or under.Any family member over the age of 16 needs to give consent by signing against their details.
First Name / Surname / Date
of Birth / Male/ Female / Relationship
(e.g.mother, father,child, partner) / Ethnicity / Education or workplace (please includeNI number) / Signature of consent
In ordertoalteryourconsent,pleaseinformthe personworkingwithyou.
This consentform should bereviewedatthecompletionof anynewassessmenttoensure it remainsan accuratereflectionofthefamilies’wishes.
Section 2:Statement of Information Sharing for Person helping to complete this form
Referrer’sName: / Signature:
Organisation: / Date:
Role: / ContactNumber:
Email:
Isthe personableto understandwhytheirinformationmaybe shared and aretheyabletomake a consentdecisiononthis basis?(Please tick and complete A or B orCbelow).
A YES and I have explainedtotheperson/theirrepresentative:
Whywe mayneedtoshareinformation.
Who we mayneedtoshareinformation with –forexample:
Police;Probation; EssexCountyCouncil i.e Social Care,YOT,EWS;Target Youth Service; Department ofWorkand Pension;Employment and Skills; District HousingDepartments andProviders;Health Providersi.e.AdultMental Health, CFCS orGeneral Practitioners; ECC ContractedPartners;School/EducationProviders;Thirdsectorproviderswho areorwho mayworkwith thefamily.
Theirrightto declinethe sharing ofsome orall ofthe information. Theirrightto withdrawconsentat anytime.
Thepersonhassigned thisform overleaf
Thatinsomecases we mayshare information withoutconsentin order
to safeguardthe vulnerable,to preventcrimeand/oriforderedbya Court.
or

BI am unableto judge this andhave referred thismatterto:

CNo, because ______
Section 3:Statement ofrepresentative (onlyto be completedwherethere may be a concern regardingtheindividuals capacityto makedecision).
Irepresentthe personnamed onthisform and:

Iagree with decisionsthathave beenmadeconcerning thesharing ofinformation

Idonotagreewith the decisions that have beenmade concerning thesharing of information because:
Name: ______/ Signature: ______/ Date: ______
Relationshipto Person: ______
Source of LegalAuthorisation,ifapplicable(forexample Legal Power of Attorney):

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Section 4:Details ofthe request(Please ensure you outline in more detail the issues you identified on page 1in this section)
Pleasestate yourreasonsformakingthis requestandwhyadditional supportis needed
Please outline anywork thathasbeen undertakenwiththefamily/individual,includingany successes
Family/Individualviews:What is thefamily/individual hoping toachievefromtherequest?
Concerns and/orrisks: Are you aware ofanyconcernsand/orrisksthatother professionalsshould be aware ofbeforecontacting orvisitingthefamily/individual:(forexample:communication difficulties,history ofaggressionto professionals,domesticabuse,dangerousdogs).
Section 5:Further Family Information
Family/individualheritage/culture/religion / Detailsof anyfamily/individualmemberswith disability(ies)
Others:(not included in Section 1, but are known to regularly attend the family address)
First Name / Surname / Age / Relationship orRole
Details ofotherprofessionalsinvolvedwiththefamily/individual
FamilyGP / Practicename / Telephone Number
Service/Agency / PractitionerName / Supportingwhich member(s) offamily / ContactNumber / Aware of Referral?
Pleaselistanyassessments/referralsthat you are aware have alreadybeen undertaken or made.
AssessmentType CAF,SocialCare,
Health, Education, other / Assessmentforwhich familymember / Date of assessment / Assessors name,service and contactdetails

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Section 6FrequentlyAsked QuestionsaboutInformation Sharing

(To be left with the Family)

Whyshare personalinformation?

Sharing personal information helpsustowork togethertosupportchildren,young people andtheirfamilies and carers. But,itisimportanttorememberthat ifyou don’t letusshare yourinformation,thiscould delayor preventyoufromgettingthe help you need.

Can Ichoosewhat personalinformationisshared aboutme?

Yes,mostofthetime we will tell you whatinformation we mightneedto passonandwho we need to passit on to.

Thetypesofinformationto beprocessedmayinclude:Name, DateofBirth,Gender,Address,and relevant informationto inform assessment.Ifthere issomething thatyou don’twantustopasson aboutyou then wewon’t.Please tell theperson working with you.

Sometimeswe have to share personal information aboutyou withoutasking yourpermission,forexample:

•Ifwe are worried aboutthe safetyofa child, young personorvulnerable adult;

•Ifwe think thatacrime may be prevented orfoundout bysharingit;or

•Ifa court orderismadein criminal orlegal cases

Can Isayno?

•You can askusnottopassyourpersonal information toanyone else at anytime

•You can saynoatfirst.You can alwayschangeyourmind lateron

•Orifyou sayyesyou can also changeyourmind later on

HowwillI gain from sharingmypersonalinformation?

•Itwill help usmake surethat you gettherightsortofhelp

•You canquicklyfind out aboutthe different typesofhelp available to you

•Youwon’tbe askedforthesameinformation lotsoftimes

Howdowesharepersonalinformation?

So thatwe can safelyshare yourpersonal information,someorganisationsin EssexsuchasEssexCounty Council,Health andthepolice have signed anagreementcalledthe EssexTrustCharter.

Thismeansthatallthe organisationsthat have signeditmustprotectyour personal information. Fordetails ofthe charterand the organisationsinvolved,ask thepersonthatisworking with you oryou canfind iton

the internet at Essex partnership portal

Can Iseewhatison myrecord?

Yes.Ifyou wanttocheckyourown recordortalkto someoneabouthow safe andconfidential yourpersonal information is,you should talk tothepersonwho isworkingwith you.

Data Protection:

Forindependent advice aboutdata protection, privacyand data sharing issues,you cancontactthe Information Commissioner’s Office,Wycliffe House,WaterLane,Wilmslow,Cheshire SK9 5AF. Tel: 01625 545745or 08456 306060 Fax:01625 524510 Website:

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