Family No:
(Office use only)
Date Referral Sent / Date referral Received
NAME / DOB / Resident In Household ü / Ethnicity / Interpreter
Required ü / Parental ü Responsibility
Main Carer
Partner
Address of family
Including Post Code
Tel No: / Mobile No:
Email for Family
(if available)
Name of Child / DOB / Gender
M/F / CP/CIN/CAF / Disability
Y/N / Ethnicity / CareFirst No / School
Referred by: / Other agencies involved with family
Name / Family GP & Contact no:
Role & Agency / Health Visitor & contact No
Address / Social Worker & Contact No
Tel: / Other agency & Contact no
Email: / Other agency & Contact no

Family Needs: So that we can offer the family the most appropriate support and match the most suitable volunteer, please complete the following. The information, together with the information provided by the family, will be used to monitor how Home-Start support meets the family’s needs.

FAMILY NEEDS / ü / Please tell us why this is a need
1) Managing Children’s Behaviour
2) Being involved in children’s development
3) Coping with own physical health
4) Coping with own Mental Health
5) Coping with feeling isolated
6) Parent’s Self-esteem
7) Coping with child’s physical health
8) Coping with child’s mental health
9) Managing the household budget
10) Day to day running of the house
11) Stress caused by conflict in the family
12) Coping with extra work caused by multiple birth/multiple under 5’s
13) Use of services
14) Other (please describe)
PLEASE TELL US IF THE FAMILY HAS ANY ISSUES RELATING TO: Please tick all that apply and state who it relates to.
Lone Parent / Substance use / Domestic abuse / Mental Health / Learning Disability / Post Natal Illness / Teenage Pregnancy / Debt
Please add any background information that you think would be useful. (if necessary please attach a separate sheet).
Are there any Health & Safety issues we need to be aware of when visiting this family or placing a volunteer in the family home?
Do the family have any pets/animals in the home? If yes please state type.
Please indicate the immigration status of the family: ü
Asylum Seeker / Refugee / Pending / Not/Applicable
Main Carer
Partner
Children:

Details of assessments of children’s needs if applicable.

Name of Child / Name of Lead Professional / fCAF / CIN / CP / CIC / SEN / Early Support Plan
1.
2.
3.
4.
5.
6.
7.
8.

Has the family consented to this referral? YES NO

Thank you for taking the time to provide this information, which will help us to process the referral.

·  We are unable to process the referral until we have received this form.

·  We will contact the referrer within 2 weeks of receipt of the referral form.

·  We will remain in contact with the referrer whilst we are supporting the family and will inform you when support begins and ends.

PLEASE NOTE:

This form will be held in confidence but may be shown to the family if requested.

Receipt of this form DOES NOT mean support is immediate; we will inform you when support begins for the family.

I confirm that I have spoken to the family about this referral and it is made with their consent.

I confirm that I have read and understand the information provided in this form.

Family’s Signature……………………………………………………………Date……………………………….

Referrer’s Signature…………………………………………………………Date………………………………

Please see next page for details of each Home-Start and the areas of coverage or return to email address on front page.

If you have any questions or concerns about the referral process or the support provided to the family please contact your local Home-Start below:

Home-Start Contact details / Wards Covered
Home-Start Bartley Green & Quinton
Doddington Green Children’s Centre
28 Doddington Grove
Bartley Green B32 4EL
Email:
Tel: 0121 675 4441 / Bartley Green
Quinton
Home-Start Birmingham North west
United Reform Church
1 Brassington Avenue
Sutton Coldfield B73 6AA

Tel: 0121 321 2277 / Sutton Four Oaks
Sutton Newhall
Sutton Vesey
Sutton Trinity
Kingstanding
Home-Start Cole Valley
116 Church Road
Yardley B25 8UX

Tel & Fax: 0121 572 0800 / Shard End
Sheldon
Stechford & Yardley North
South Yardley
Sparkbrook
Nechells South
Ladywood
Home-Start Birmingham South
Hampstead House
Condover Road
West Heath B31 3QY

Tel: 0121 476 3759 / Weoley
Northfield
Longbridge
Kings Norton
Home-Start Stockland Green/Erdington
Erdington Baptist Church
Wood End Road
Erdington B24 8AD

Tel: 0121 373 1376 Fax: 0121 572 5427 / Stockland Green
Erdington
Aston
Home-Start Castle Vale & Pype Hayes
The Sanctuary
Tangmere Drive
Castle Vale B35 7PX

Tel: 0121 747 4631 Fax: 0121 748 3301 / Castle Vale
Tyburn
Hodge Hill