Somerset Phoenix Project

Request for Support Form

*** Professionals only ***

(The boxes highlighted in yellow are mandatory to assess if referral meets SPP criteria)

*Do you have consent to share information about this child?
Please state YES or NO
Has the child/YP given consent to this request form being sent in?
Consent is essential. Please state Yes or No.
Does the child/YP (over age of 13 years) consent to the professionals in their lives being contacted?
ABOUT THE CHILD
Date initial enquiry received:
Today’s date (completion of form):
Referring Agency:
Where did you hear about us?
First name:
Surname:
*Age:
Date of birth:
Gender identified with:
Religion/Belief:
Ethnicity:
Disability/SEN:
Child / Young Person’s current address:
Child / YP’s current contact details: (If the Young person is over the age of 13 we must have the best phone number to contact them on) Please indicate whether the young person wants to be contact by their parents, through school/college or directly.
Is it OK to:
Call
Text
Leave a message / Young person’s phone number:
Who does the young person want to contact first to make initial contact:
Yes/No
Yes/No
Yes/No
*Does the child/YP live in Somerset:
*Is the child/young person at current risk of CSA? (Please state YES or NO)
When did the abuse stop?
*Did the abuse involve physical contact?
(Please refer to NSPCC guidelines if unsure)
Please state YES or NO
Has the child/YP has CAMH’s involvement?
Please state Past, Current or Referral to CAMHS submitted
What relationship does /did the perpetrator of the abuse have to the child/ young person?
What is the current location of the perpetrator? (if known)
Has the child/ young person experienced CSE? Please state yes or no
Is there or has there ever been a CP Plan or Child in Need plan for this child?
Please state None, Current or Historic
If current CP plan please state social worker’s name:
Date of the next Children’s Social Care meeting? (Core Group/RCPC/CIN etc.)
Is this child in care now or have they ever been in care?
Please state yes or no
If yes please comment:
Has an Early Help Assessment been completed on the child? Please state yes or no
If yes, please attach a copy to this request form.
When is the next TAC/TAF meeting:
Is there a current court case or police investigation?
Please state None, Current or Historic
How did the child come to the attention of the referring agency?
Please give details of the referring agencies involvement:
Current school/college name and address
Key professional name
BACKGROUND SUMMARY & SUPPORT NEEDED
Family background & significant life events e.g. family dynamics, bereavements, family separations, house moves, changes in educational provision:
Details of Childhood Sexual Abuse experienced:
Details of the child’s current presenting behaviours and emotional difficulties:
Details of support/intervention already received:
Summary of current protective factors for the child/young person:
Summary of current risk factors for the child/ young person:
What support are you requesting from the Somerset Phoenix project?
The Phoenix service is commissioned by Somerset County Council to provide support to professionals/parents/carers working with children and families who have experienced childhood sexual abuse. On receipt of this ‘request for support’ form we will post out (if safe to do so) our Service Information Guides to families.
Keeping in mind that the primary purpose of Phoenix is to support professionals to develop their capacity to offer the most effective support possible to the families and children they support please consider which option below may be the most supportive.
Available to all (please highlight which option you are requesting)
Professional consultation: for you and the other professionals involved with one of our specialist therapist to work on an action plan of support
Parent/Carer support in a small group
Training
We have very limited capacity to provide one to one direct support to a child, young person or parent/carer and anticipate demand for this will exceed the capacity of our small team of 2 Full Time Equivalent Staff for the whole county. Please prioritise the options above but if you still feel the options listed below may be appropriate please indicate this. We cannot guarantee availability of this support.
(please highlight which option you are requesting)
One to one specialist support for the child or young person – this is holistic family support that is trauma informed. It works on relationship building, stabilisation, how trauma has affected the young person and the wider family, ways to move forward.
One to one counselling/play therapy – Works on relationship building, managing the ‘symptoms’ of abuse, how trauma has affected the young person, ways to move forward.
OTHER AGENCIES & PROFESSIONALS INVOLVED WITH SUPPORTING THE CHILD/YP
E.g. Domestic Abuse Service/Drug & Alcohol Service/Mental Health Service
Name of Professional / Agency & Job Role / Contact Details / Name of parent/carer being supported / Permission to Contact? (Y/N)
ABOUT THE REST OF THE FAMILY: ALL THE SIBLINGS AGED UNDER 18
(If you would like to refer additional family members please complete separate forms)
SIBLING 1
First name:
Surname:
Age:
Date of birth:
Gender:
SIBLING 2
First name:
Surname:
Age:
Date of birth:
Gender:
SIBLING 3
First name:
Surname:
Age:
Date of birth:
Gender:
Do all the children listed above live with the parent/carer?
Please provide details…
ABOUT THE MAIN PARENT/MAIN CARER
Full name:
Relationship to child:
Address:
Postcode:
Mobile / Home Tel:
Is it OK to:
Call
Text
Leave a message
Email address:
Disability (physical / learning):
Please provide specific details if known
Mental health
Please provide specific details if known
Domestic abuse
Please provide specific details if known
Substance misuse
Please provide specific details if known
Does the parent have PR (if child under 18 years)? Please state yes or no
ABOUT OTHER PARENT / CARERS (WHERE RELEVANT)
Full name:
Relationship to child:
Address:
Postcode:
Mobile / Home Tel:
Is it OK to:
Call
Text
Leave a message
Email address:
Disability (physical / learning):
Please provide specific details if known
Mental health
Please provide specific details if known
Domestic abuse
Please provide specific details if known
Substance misuse
Please provide specific details if known
Does the parent have PR (if child under 18 years)? Please state yes or no
OTHER SIGNIFICANT ADULTS
E.g. Step-parents /Grandparents/ Aunts / Uncles
Name / Address/Tel / Relationship to Child
OTHER AGENCIES & PROFESSIONALS INVOLVED WITH SUPPORTING MAIN PARENT/MAIN CARERS
E.g. Domestic abuse service / Drug & Alcohol Service / Mental Health Service
Name of Professional / Agency & Job Role / Contact Details / Name of parent/carer being supported / Permission to Contact? (Y/N)
PROFESSIONAL INVOLVEMENT
ABOUT THE AGENCY REQUESTING SUPPORT
Name:
Agency:
Date:
Contact number:
Address:
Email:
RETURNING THE FORM & WHAT HAPPENS NEXT
Returning the Form:
Please email this form and any additional documents, e.g. EHA, to:

Please note: All emails must be sent via a secure / encrypted network. If you do not have access to a secure email system please contact the Phoenix Team on 07590 627 693 and we can generate one for you.
Also please note that referrals to the manager or workers direct email account will not be processed.
What happens next?
Each request for support will be considered by the Phoenix Team at a Triage meeting.
Triage meetings occur on the 2nd and 4th Wednesday of each month. If needed, we will contact you for more information. It is therefore important that this form is completed in as much detail as possible.
Once the request for support has been considered at Triage a member of the Phoenix Team will contact you with the outcome
Please note: the Phoenix Team operates on Monday, Tuesday & Wednesday (10am-4pm).
FOR COMPLETION AT THE TRIAGE MEETING
Brief notes of discussion:
Summary of outcome:

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