- REFERRER INFORMATION
Family eStart / Mosaic ID / Referrer’s agency/service*
Referrer’s name* / Referrer’s telephone*
Referrer’s email *
This must be provided for
the referrer to receive feedback
If the family has a named social worker, it is your responsibility as the referrer to ensure the social worker is made aware of and in agreement with this referral being made.
- FAMILY INFORMATION
PRIMARY CARER 1 (e.g. mother/father) / PRIMARY CARER 2 (e.g. mother/father)
Name* / Name*
Telephone* / Telephone*
Date of birth / Date of birth
Address and postcode* / Address and Postcode*
Contact email
All booking information will be sent via email. / Contact email:
All booking information will be sent via email.
Relationship to child* / Relationship to child*
Lone parent? / Yes / No / Lone parent? / Yes / No
Disabilities / Health needs / Yes / No / Disabilities / Health needs / Yes / No
Special Educational Needs / Yes / No / Special Educational Needs / Yes / No
Ethnicity / Ethnicity
First Language / First Language
Is support required with speaking, writing or
reading English?* / Is support required with speaking, writing or
reading English?*
CHILDREN / Gender / Disability /
Health needs / Special Educational Needs
Child1* / Name: / Male / Female / Yes/No / Yes/No
Date of Birth:
Ethnicity:
Name of Preschool/Nursery/School/Childminder
Child 2* / Name: / Male / Female / Yes/No / Yes/No
Date of Birth:
Ethnicity:
Name of Preschool/Nursery/School/Childminder
Child 3* / Name: / Male / Female / Yes/No / Yes/No
Date of Birth:
Ethnicity:
Name of Preschool/Nursery/School/Childminder
Child 4* / Name: / Male / Female / Yes/No / Yes/No
Date of Birth:
Ethnicity:
Name of Preschool/Nursery/School/Childminder
3. REFERRAL INFORMATION This section must be fully completed with as much detail as possible *
Please outline what is currently working well for the family(continue on additional sheet if necessary)
Please outline what you or the family are worried about
4. SERVICE REQUEST*
Complete the following sections to indicate which service or services are being requested.
You must make sure that you tick the boxes to confirm that the family meet the eligibility criteria for the service requestedand indicatevia the tick boxesthat the required supporting information is attached.
Family and Parenting Support
Support provided through either one-to-one work with a family in the home or in a children’s centre or through attendance at a group programme. This includes specialist family support for children with SEN and disabilities. Programmes include:
- Incredible Years- Baby Programme: A programme supporting early attachment and brain development
- Stepping Stones- A parenting programme for parents of children with SEN anddisabilitiessupporting them to promote positive behaviour and manage challenges
- Personalised IndividualisedParenting Therapy (PIPT)–An intensive programme delivered by a parenting therapist for parents of children with challenging behaviour, often delivered in the home on a one-to-one basis
- One-to-One Home Visiting programme (including specialist service for children with SEN)-A Family Support Worker will carry out direct work with children and family members to bring about positive change as part of an action plan developed from an assessment of need.If this service is requested, do not request any other services at this time as other services will be considered as part of the action-planning with the family.
Age Criteria / 0 to end of Receptionyear / Eligibility Criteria / Family assessed/evidenced as having needs at the Green, Amber or Red tier of need in the Merton’s Child, Young Person and Family Well Being Model ♣ORParent supported at Health Visiting level 2, 3 or 4and section 3 (above) is complete with supporting information ☐
Supporting Evidence / Single Assessment ☐ / Early Help Assessmentor CASA ☐ / Behaviour or SEN Support Plan ☐ / CAMHS Care Plan ☐ / Parental Mental Health or Health Assessment ☐ / EHCP ☐ / Other Specialist Assessment ☐
Name of child requiring service
Early Learning Together Baby Programme
A 5 week group programme supporting parents to understand their baby’s early brain development, learn massage strokes to aid comforting and soothing their baby and receive information and advice about activities and other support services available in the local area.
Age Criteria / 0 to 7 months old / Eligibility Criteria / First time parent (no supporting evidence required) ☐
ORFamily assessed/evidenced as having needs at the Green, Amber or Red tier of need in Merton’s Child, Young Person and Family Well Being Model ♣ORParent supported at Health Visiting level 2, 3 or 4 and section 3 (above) is complete with supporting information ☐
Supporting Evidence / Single Assessment ☐ / Early Help Assessmentor CASA ☐ / Parental Mental Health or Health Assessment ☐ / Other Specialist Assessment ☐
Name of child requiring service
Early Learning Together Toddler Programme
A 7 week group programme supporting parents to understand their child’s development, learn about activities and games they can play with their child that support early learning and parent and child interaction.
Age Criteria / 8 to18 months
OR
19 to 36 months / Eligibility Criteria / Family assessed/evidenced as having needs at the Green, Amber or Red tier of need in Merton’s Child, Young Person and Family Well Being Model ♣ORParent supported at Health Visiting level 2, 3 or 4 andsection 3 (above) is complete with supporting information ☐
OR ASQ scoring in grey range for any one domain☐
OR Family in worklessor low income householdAND the parent requires support to understand stages of development and their role in supporting this ☐
Supporting Evidence / Single Assessment ☐ / Early Help Assessmentor CASA ☐ / ASQ score summary ☐ / CAMHS Care Plan ☐ / Parental MentalHealth or Health Assessment ☐ / Other Specialist Assessment ☐
Name of child requiring service
Early Learning Together Preschool Programme
A 7 week group programme for children and parents to experience a nursery / pre school type setting, aiming to help parents and children to manage separation and prepare for a smooth transition into nursery / pre school, alongside developing children’s early learning.
Age Criteria / 20 to 36 months / Eligibility Criteria / Child eligible for free early education for 2 year olds ☐
ANDparent has not taken up offer of free place ☐
Supporting Evidence / Eligibility can be checked at
Name of child requiring service
Talking Together
A 7 week group programme supporting parents to understand the importance of their role in developing their child’s speech and language.
For children where delay isconsidered to be due to environmental (parenting) factors.
Age Criteria / 26 to 36 months / Eligibility Criteria / Communication language is delayed between 3-12 months in at least 1 area but a referral for specialist support is not currently appropriate: Attention and listening ☐ Speaking ☐ Understanding ☐
ORASQ3 Scoring in grey range for either Communication, Personal and Social or Problem Solving OR child referred for review in 3 months but a referral for specialist support is not currently appropriate ☐
ANDChild does not meet criteria for ECOM or SOCOM ☐
AND Child not attending early education setting (nursery)☐
Supporting Evidence / ASQ3 Score Summary ☐ / Observation / Assessment evidencing delay☐
Name of child requiring service
Early Communication (ECOM) Group
Group to support children to interact with family members and other familiar people. Children and their parents develop communication with one another using sounds, gestures, pictures and symbols. For children where delay is not thought to be environmental (parenting).
Age Criteria / 26 months - reception start age / Eligibility Criteria / Child’s communication and language is at least 6 months delayed in all three areas and a referral to SALT and or paediatrician has been made: Attention and listening ☐ Speaking ☐ Understanding ☐
OR ASQ3 Scoring in grey or black for either Communication, Personal Social or Problem Solving and a referral to SALT and or paediatrician has been made☐
ANDChild does not meet criteria for Talking Together or SOCOM ☐
AND Child not attending early education setting i.e. nursery/reception☐
Supporting Evidence / ASQ3 Score Summary ☐ / Observation / Assessment evidencing delay ☐ / SALT/Paediatrician referral/report ☐ / Other Specialist Assessment ☐
Name of child requiring service
Early Learning Together 1 to 1 Programme
A 6 week programme delivered in the family home, helping parents to understand their child’s development, learn about
activities and games they can play with their child that support early learning and parent child interaction.
Age Criteria / 0 to 36 months / Eligibility Criteria / Family assessed/evidenced as having needs at the Green, Amber or Red tier of need in Merton’s Child, Young Person and Family Well Being Model ♣ORParent supported at Health Visiting level 2, 3 or 4 and section 3 (above) is complete with supporting information ☐
AND Parent requires support to understand development stages and their role in supporting this ☐
ANDFamily unable to attend a group programme (please provide details in section 3 above) ☐
Supporting Evidence / Single Assessment ☐ / Early Help Assessment or CASA ☐ / EHCP ☐ / CAMHS Care Plan☐ / Parental Mental Health Assessment☐ / Other Specialist Assessment ☐
Name of child requiring service
Social Communication (SOCOM) Group
Group to support children with ASD or Social Communication Disorder to communicate with their family members and other familiar people. Children and their parents will develop communication with using sounds, gestures, pictures and symbols.
Age Criteria / 32 to end of reception / Eligibility Criteria / Child has diagnosis of ASD or Social Communication Disorder (or in process of assessment) ☐
AND Child’s communication and language is at least 12 months delayed in all three areas below:
Attention and listening ☐ Speaking ☐ Understanding ☐
AND Child doesn’t attend specialist setting, but lives in or attends a mainstream setting in Merton ☐
Supporting Evidence / EHCP ☐ / Paediatric Report / Assessment ☐ / Specialist Report / Assessment ☐ / SALT report ☐ / ASQ SE ☐
Name of child requiring service
Portage Services
An education programme delivered through group sessions and/or one-to-one home visiting for children with
very complex special needs and / or disabilities, delivered by trained Portage workers.
Age Criteria / 0 to 36 months / Eligibility Criteria / Child with complex special needs in 2 areas:
Cognition and Learning ☐ Social, Emotional and Mental Health ☐
Communication and Interaction ☐ Sensory or Physical ☐
ANDChild does not attend and early education setting ☐
Supporting Evidence / Paediatric Report / Assessment ☐ / Specialist Report / Assessment ☐
Name of child requiring service
♣The MertonChild, Young Person and Families Well Being Model and indicators can be accessed at refer to this when considering eligibility for services
5. PARENT / CARER VIEWS*Use this space for the family to record their views about how the service or services requested will support them and what they hope to gain from this
6. CONSENT*
Data Protection Agreement / The information you provide will be held by Merton Council and may be used by the Council and other children’s centre partner organisations. This information will be used to help keep you informed about services for you and your family in your local area, it will also be used to help us monitor and improve those services in the future. If you have any further questions about the organisations who make up the Children’s Centre Teams or how your information will be used, please speak to a member of the team or visit
WE MAY CONTACT YOU BY PHONE TO DISCUSS THIS REFERRAL AND / OR TO BOOK YOU ONTO A PROGRAMME –PLEASE NOTE THAT THIS WILL BE FROM AN UNKNOWN NUMBER
Parent’s Signature / Date:
Verbal consent received / Yes / No
Please check that you have completed the form fully before sending it
Please note that some services will require further assessment to determine suitability. The referrer and parent / carer will always be advised of the outcome and will receive confirmation of the service(s) offered.