REFERRAL FOR CHILD PROTECTION SERVICE

INFORMATION ABOUT REFERRER
Date / Service referring:
Name of referrer: / Referrer’s contacts:
Referred by (tick one box): / Self / Family / School / Other (specify):

SECTION A: Information about Service User or Provider being referred

Please fill in a separate Section A for each person being referred for service. These persons will be direct service users of APPOGG.

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Legal name / Legal surname
Name known as
Id card no./Passport no.
Date of birth and current age
day / month / year / Age
Sex
Male / Female
Contact address
Dwelling no/name
Street
Town
Postcode
Telephone numbers
Landline
Mobile
Phone restrictions (tick if yes)
Nationality
Maltese / Other (specify)
Country of birth
Malta / Other (specify)
Preferred language of expression (please circle only 1) and level of spoken/expressed language*
*1=very good; 2=understandable; 3=poor; 4=not at all; NA
Maltese / Other 1(specify)
English / Other 2(specify)
Residential status
Resident of Malta / Refugee status
Other (specify)
Current marital status (tick one)
Single / Annulled
Co-habitating / Divorced
Married / Widowed
Separated
Current occupation
Employee  / Full-time
Self-employed  / Part-time
Homemaker / Summer job
Pensioner
Unfit to work / Work or school details:
Unable to work
Unemployed
NEET (-16)
Pupil/student
Type of occupation / or school
Custody Status (if applicable)
Care Order / Voluntary care
Court Order
Name of Custodians (if applicable)

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Additional Notes:

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For office use only
File Number: / Family code: / Allocation Date:
Worker allocated / Method of referral

SECTION A continued:

Additional Service User or Provider being referred:

Please fill in a separate Section A for each person being referred for service. These persons will be direct service users of APPOGG.

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Legal name / Legal surname
Name known as
Id card no./Passport no.
Date of birth and current age
day / month / year / Age
Sex
Male / Female
Contact address
Dwelling no/name
Street
Town
Postcode
Telephone numbers
Landline
Mobile
Phone restrictions (tick if yes)
Nationality
Maltese / Other (specify)
Country of birth
Malta / Other (specify)
Preferred language of expression (please circle only 1) and level of spoken/expressed language*
*1=very good; 2=understandable; 3=poor; 4=not at all; NA
Maltese / Other 1(specify)
English / Other 2(specify)
Residential status
Resident of Malta / Refugee status
Other (specify)
Current marital status (tick one)
Single / Annulled
Co-habitating / Divorced
Married / Widowed
Separated
Current occupation
Employee  / Full-time
Self-employed  / Part-time
Homemaker / Summer job
Pensioner
Unfit to work / Work or school details:
Unable to work
Unemployed
NEET (-16)
Pupil/student
Type of occupation / or school
Custody Status (if applicable)
Care Order / Voluntary care
Court Order
Name of Custodians (if applicable)

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Additional Notes:

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For office use only
File Number: / Family code: / Allocation Date:
Worker allocated / Method of referral:

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SECTION A: OTHER FAMILY MEMBERS OR SIGNIFICANT OTHERS’ INFORMATION

Please fill in the information below for other family members or relevant persons.Each person is recorded in a separate column. These are not direct service users but are important contacts. This may consist of Parents, extended family members, Foster carers, Biological Parents, Neighbours, Friends Etc.

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Other family member or significant other
Relationship to:
Marital Partner / Other Partner
Child
Parent / Specify other:
Other 
Legal name / Legal surname
Name known as
Id card no./Passport no.
Date of birth and current age
day / month / year / Age
Sex
Male / Female
Nationality
Maltese / Other (specify)
Residential status
Resident of Malta / Refugee status
Other (specify)
Contact address
Tick if the address is the same as related person
Dwelling no/name
Street
Town
Postcode
Other contact Telephone numbers
Landline
Mobile
Current occupation
Employee / Unfit to work
Self-employed / Unable to work
Homemaker / NEET (-16)
Pensioner / Pupil/student
Unemployed
Type of occupation / or School
Other family member or significant other
Relationship to:
Marital Partner / Other Partner
Child
Parent / Specify other:
Other 
Legal name / Legal surname
Name known as
Id card no./Passport no.
Date of birth and current age
day / month / year / Age
Sex
Male / Female
Nationality
Maltese / Other (specify)
Residential status
Resident of Malta / Refugee status
Other (specify)
Contact address
Tick if the address is the same as related person
Dwelling no/name
Street
Town
Postcode
Other contact Telephone numbers
Landline
Mobile
Current occupation
Employee / Unfit to work
Self-employed / Unable to work
Homemaker / NEET (-16)
Pensioner / Pupil/student
Unemployed
Type of occupation / or School

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SECTION Acontinued:

Other family members of significant others

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Other family member or significant other
Relationship to:
Marital Partner / Other Partner
Child
Parent / Specify other:
Other 
Legal name / Legal surname
Name known as
Id card no./Passport no.
Date of birth and current age
day / month / year / Age
Sex
Male / Female
Nationality
Maltese / Other (specify)
Residential status
Resident of Malta / Refugee status
Other (specify)
Contact address
Tick if the address is the same as the Person A
Dwelling no/name
Street
Town
Postcode
Other contact Telephone numbers
Landline
Mobile
Current occupation
Employee / Unfit to work
Self-employed / Unable to work
Homemaker / NEET (-16)
Pensioner / Pupil/student
Unemployed
Type of occupation / or School
Other family member or significant other
Relationship to:
Marital Partner / Other Partner
Child
Parent / Specify other:
Other 
Legal name / Legal surname
Name known as
Id card no./Passport no.
Date of birth and current age
day / month / year / Age
Sex
Male / Female
Nationality
Maltese / Other (specify)
Residential status
Resident of Malta / Refugee status
Other (specify)
Contact address
Tick if the address is the same as the Person A
Dwelling no/name
Street
Town
Postcode
Other contact Telephone numbers
Landline
Mobile
Current occupation
Employee / Unfit to work
Self-employed / Unable to work
Homemaker / NEET (-16)
Pensioner / Pupil/student
Unemployed
Type of occupation / or School

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SECTION B: CHILD PROTECTION SERVICE REFERRAL

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Information about the abuse
Type of abuse (check box/es):
Physical / Sexual / At Risk / Neglect / Emotional / Cybercrime
Is the child aware of the referral?
Yes / No
Are the parents aware of the referral?
Yes / No
Information about the alleged perpetrator
Legal name / Legal surname / ID Card Number
Address
Related to Victim (check one box)
Yes / No / Specify Relationship:

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Professional Support
(list all professionals involved with the child)
Name of Professional: / Address/Designation: / Contact Details:
Name of Professional: / Address/Designation: / Contact Details:
Name of Professional: / Address/Designation: / Contact Details:
Name of Professional: / Address/Designation: / Contact Details:
Name of Professional: / Address/Designation: / Contact Details:
Is the child aware of the referral?
Yes / No
Are the parents aware of the referral?
Yes / No
Reasons for Referral:
(be clear about who has concerns and whether they are being reported as facts or speculation)
Summary of Concerns:
(focus on the child’s needs and the risks to the child)
Present Situation:
Additional Comments:
Person(s) Making/Taking Referral: / Signature(s): / Date:
(For office use only) / Senior on Duty (consulted): / Signature: / Date:
Initial Risk Assessment:
Very High / High / Moderate / Low
Initial Action Plan:

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