Referral for Child Protection Service

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.

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)

Additional Notes:

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.

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)

Additional Notes:

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

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.

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

SECTION Acontinued:

Other family members of significant others

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

SECTION B: CHILD PROTECTION SERVICE REFERRAL

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:

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: