Early Help Division
Request for Parenting Support /
Please send completed & signed form to:
Louise Donaldson & Suzanne Clements
Parenting Co-Ordinators
Complex Families
Early Help Division
Families and Wellbeing Directorate
Warrington Borough Council
2nd Floor Newtown House
Buttermarket Street
Warrington
WA1 2NH
01925 444266
01925 442894
mailto: /

FOR OFFICE USE ONLY

Date form received:

Date form Screened:
Date Screening Tool sent:
Outcome: Appropriate/Not Appropriate
Name of Parenting Programme:
PP number:
Complex Families number:
Please note referrals will be returned ifFULL WRITTEN CONSENTis not obtained at point of referral

REFERRING AGENCY DETAILS

Name:
Role:
Agency:
Address:
Telephone number:
Email address:

Please note that requests for parenting support will NOT be accepted for consideration without an assessment of Parenting Capacity (this includes professional opinion/judgement)

Type of Assessment: / Date of Assessment: / Details of Lead Professional if different from referrer:
CAF
Whole Family Assessment
Early Help Assessment
Combined Assessment
Other (please state)
Parent/Carer Name / Parent/Carer Name
Date of Birth / Date of Birth
Address / Address
Postcode / Postcode
Landline Number / Landline Number
Mobile Number / Mobile Number
Email / Email
Disability
Learning or physical
Please state / Disability
Learning or physical
Please state
Ethnic Origin / Ethnic Origin
Language interpreter needed? / Language interpreter needed?
Names of children / Date of birth / Gender / Disability Learning or Physical
Please state / Nursery
or school / EHCP
SEND / Address if different
Reason for Request:
  • From your assessment of parenting capacity please detail specific concerns
  • Please detail specific child behaviours if causing concern i.e. self harm, CSE, other risk taking behaviours
  • Confirm that the parent(s)/carer(s)have no issues preventing their full participation in the programme i.e. medical appointments; transport or childcare

From your assessment of parenting capacity and needs identified what outcomes do you expect the parents/carersto achieve from attending the parenting programme. (Please be as specific as possible)
Please give details of allservices / interventions currently in place for individuals and family
Please detail what continuing support the Lead Professional/Referrer will provide to the parent(s)/carer(s) and child(ren) during and after the programme to monitor, embed strategies and ensure changes are sustainable
Any other information we might need to know in working with this family including risks/issues?
Risk / Issue / Please specify
History of violence/aggression
Racial discrimination/prejudice
Court proceedings planned or in progress
Other risks/concerns

CONSENT

Please note referrals will be returned ifFULL WRITTEN CONSENTis not obtained at point of referral
Consideration for Strengthening Families will require consent from the child if aged 12 or above at point of referral
REFERRER
I confirm that I have discussed Information sharing and storing with the family
I confirm that I have discussed this request for involvement with the individual and/or family and the family understand that I will be supporting them through the duration of the programme.
I agree to attend a joint visit with course co-ordinator/facilitator and to be the named contact for the Early Help Division.
Signed (Referrer) Name Date
INDIVIDUAL / FAMILY
I have had the parenting referral explained to me and agree to this request for support.
I understand that the information recorded on this form and other information obtained about me and my family will be shared with the Early Help Division and other relevant Local and National agencies, We may share and use your information to: -
•Identify your needs and the level of support you require
•Be able to tell other Public Services what support you need from them
•Make sure the Services you currently work with know what is happening
•Make sure that the services the Partnership provide are effective and help people across Warrington
•We might also share information to assess whether our services are working effectively and to improve our services for the future. This includes sharing with the government to conduct research on the impact and outcomes of services paid for by public money
I understand that information gathered on this referral will be screened for eligibility for monitoring by Complex Families
I understand that information gathered by the Parenting Co-Ordinators will be stored securely on computer or paper files and will be used for identifying a relevant parenting programme.
I am aware that consent can be withdrawn at any time and I can limit the type of information shared and who it is shared with by informing the referrer.
Signed (Parent/Carer) Name Date
Signed (Parent/Carer) Name Date
Signed (Child) Name Date
Signed (Child) Name Date