Swindon Family Contact Point /Multi Agency Safeguarding Hub (MASH)
Swindon Family Contact Point /Multi Agency Safeguarding Hub (MASH)
Referral Form
This form should be used to make a written referral regarding child protection or complex child in need concerns and to record a parent or young person’s consent to a referral being made to Children’s Services. Using this form will help make sure the response to the referral is as effective as possible. Urgent referrals should always be made by telephone, followed by completion of this form within 24 hours of a telephone referral in order to confirm the referral and record consent.
Once completed please send to and encrypt/secure via Egress. If you do not have Egress please contact us first on 01793 466903 to acquire a secure link.
Date Referral Received: / Click here to enter a date.Details of Child / Young Person being referred
Surname: / First names:
Click here to enter text. / Click here to enter text. /
Other known as names:
Please record all names child / young person have been/are known by. / DoB or EDD: / Gender:
Click here to enter text. / Click here to enter a date. / Select Gender
Home Address:
This is child/young person’s usual or home address. If child is living away from home or where the parents have shared care, the child/young person may have 2 addresses. / Postcode: / Telephone/Mobile:
All known telephone numbers should be given
Click here to enter text. / Click here to enter text. / Click here to enter text. /
Current address if different from above: / Postcode: / Telephone/Mobile:
Click here to enter text. / Click here to enter text. / Click here to enter text. /
Reason for residence at this address:
Please indicate if child is in Private Fostering arrangement.
Click here to enter text. /
Child / Young Person’s Ethnicity (please tick)
The child / young person or the child’s parents should be asked which ethnic group the child belongs to. This information will enable local authorities to complete statistical returns to DoH and plan appropriate services
Black or Black British / Asian or Asian British / White / Mixed / Other Ethnic Groups
Caribbean / ☐ / Indian / ☐ / White British / ☐ / White &
Black Caribbean / ☐ / Chinese / ☐
African / ☐ / Pakistani / ☐ / White Irish / ☐ / White & Black African / ☐ / Any other
ethnic group / ☐
Any other Black
background / ☐ / Bangladeshi / ☐ / Any other
White background / ☐ / White & Asian / ☐ / Not given / ☐
Any other
Asian background / ☐ / Any other Mixed background / ☐ / If other, please
specify:
Click here to enter text. / ☐
Any further details regarding child / young person’s ethnicity:
Click here to enter text. /
Child / young person’s religion: / Child / young person’s first language:
Select religion. / Select Language
Child/young person’s nationality (if not British)
EU citizens are not required to register with the Home Office
Nationality: / Home Office Registration Number:
Select Nationality / Click here to enter text. /
Immigration Status
Asylum seeking / ☐ / Discretionary leave to remain (DLR) / ☐ / Other immigration status, please state below / ☐
Refugee status / ☐ / HumanitarianProtection (HP) / ☐ / Click here to enter text. /
Child/Young Person: Disabled
Note for Children’s Services staff: impairment type should be recorded using children in need census codes.
The Child / Young Person is Disabled?
Yes / ☐ / No / ☐
If yes, please record type of impairment: / Select a disability.
The Child / Young Person has a Statement of SEN?
Yes / ☐ / No / ☐ / Not Known / ☐
Details of Mother
Is Mother Main Carer? / Yes / ☐ / No / ☐
Surname: / First name:
Click here to enter text. / Click here to enter text. /
Other known as names: / DoB: / Ethnicity: / First language
Click here to enter text. / Click here to enter a date. / Select ethnicity / Select Language
Home Address: / Postcode: / Telephone/Mobile:
Click here to enter text. / Click here to enter text. / Click here to enter text. /
Does Mother have PR? / Yes / ☐ / No / ☐
Details of any disability: / Select a disability.
Details of Father
Is Father Main Carer? / Yes / ☐ / No / ☐
Surname: / First name:
Click here to enter text. / Click here to enter text. /
Other known as names: / DoB: / Ethnicity: / First language
Click here to enter text. / Click here to enter a date. / Select ethnicity / Select Language
Home Address: / Postcode: / Telephone/Mobile:
Click here to enter text. / Click here to enter text. / Click here to enter text. /
Does Father have PR? / Yes / ☐ / No / ☐
Details of any disability: / Select a disability.
Details of Main Carer if not Mother or Father
Surname: / First name:
Click here to enter text. / Click here to enter text. /
Other known as names: / DoB: / Ethnicity: / First language
Click here to enter text. / Click here to enter a date. / Select ethnicity / Select Language
Home Address: / Postcode: / Telephone/Mobile:
Click here to enter text. / Click here to enter text. / Click here to enter text. /
Relationship to Child / Young Person / Select a relationship
Details of any disability: / Select a disability.
Siblings of Child/Young Person and other household members, living at home address
Note – if you have significant concerns about siblings or another child in the household these should be clearly defined above
A drawn genogram (family tree) would help understand the child within the family.
Surname / First name / DoB / Relationship / Tick if concerns for siblings also
Click here to enter text. / Click here to enter text. / Click here to enter a date. / Click here to enter text. / ☐ /
Click here to enter text. / Click here to enter text. / Click here to enter a date. / Click here to enter text. / ☐ /
Click here to enter text. / Click here to enter text. / Click here to enter a date. / Click here to enter text. / ☐ /
Click here to enter text. / Click here to enter text. / Click here to enter a date. / Click here to enter text. / ☐ /
Click here to enter text. / Click here to enter text. / Click here to enter a date. / Click here to enter text. / ☐ /
Click here to enter text. / Click here to enter text. / Click here to enter a date. / Click here to enter text. / ☐ /
Siblings of Child/Young Person and significant others, living at different address
This section records all children/young people and adults living at the child/young persons usual or home address but not already recorded above
Surname / First name / DoB / Relationship / Address / Telephone / Tick if concerns for siblings also
Click here to enter text. / Click here to enter text. / Click here to enter a date. / Click here to enter text. / Click here to enter text. / Click here to enter text. / ☐ /
Click here to enter text. / Click here to enter text. / Click here to enter a date. / Click here to enter text. / Click here to enter text. / Click here to enter text. / ☐ /
Click here to enter text. / Click here to enter text. / Click here to enter a date. / Click here to enter text. / Click here to enter text. / Click here to enter text. / ☐ /
Click here to enter text. / Click here to enter text. / Click here to enter a date. / Click here to enter text. / Click here to enter text. / Click here to enter text. / ☐ /
Click here to enter text. / Click here to enter text. / Click here to enter a date. / Click here to enter text. / Click here to enter text. / Click here to enter text. / ☐ /
Click here to enter text. / Click here to enter text. / Click here to enter a date. / Click here to enter text. / Click here to enter text. / Click here to enter text. / ☐ /
Has an Early Help Record and Plan been completed?
Yes / ☐ / No / ☐ / Don’t know / ☐
Please attach copy of completed Early Help Record and Plan and provide details of any Lead Professionals: Names and Contact Details:
Click here to enter text. /
If No, why is an RF1 more appropriate than an Early Help Record and Plan being offered?
Click here to enter text. /
Reasons for Referral:
What has happened / changed today for your concerns to reach Child Protection / Complex Child in Need level?
Please ensure all details on the Referral Form are completed as fully as possible, even if already provided verbally
Click here to enter text. /
What are we worried about? How is the current situation impacting on the Child/Young Person. Please include the family environment and views of the child:
Click here to enter text. /
What is working well? What strengths and protective factors does the Child/Young Person have?
Click here to enter text. /
What needs to happen next? What positive outcomes are you hoping for?
Click here to enter text. /
What action or steps have already been taken to reduce impact on the Child/Young Person?
Click here to enter text. /
Are there any court orders relating to the Child/Young Person or family?
Yes / ☐ / No / ☐ / Don’t know / ☐
Please Provide details:
Click here to enter text.
What key agencies are involved in supporting this child/young person/family?
Agency: / Name: / Address: / Telephone:
Select an Agency
Select an Agency
Select an Agency
Select an Agency
For LADO Referrals Only
Please add details of adult subject to allegation
If you have a safeguarding concern about a person who works or volunteers with children please ensure this section is completed
If you are unsure and require advice about making a referral please contact the Swindon LADO
Surname: / First Name:
Click here to enter text. / Click here to enter text.
DoB: / Disability? / Ethnicity?
Click here to enter a date. / Select a disability. / Select ethnicity
Address: / Job / Role: / Employer:
Click here to enter text. / Click here to enter text. / Click here to enter text.
Agency: / Employment Status:
Select an Agency / Select an employment status
Any Other Employment Details:
Details of person making referral
Please add details of adult subject to allegation
Name / Role & Agency / E-mail Address
Click here to enter text. / Click here to enter text. / Click here to enter text.
Agency Address / Telephone Number / Fax Number
Click here to enter text. / Click here to enter text. / Click here to enter text.
Referrer’s Signature / Date: / Click here to enter a date.
Parent(s) / Carer(s) Consent
For issues about consent and confidentiality please see last page
Consent for a referral should be obtained unless doing so would place a child at risk, if in doubt, please contact MASH for advice. At least one person with Parental Responsibility is required to sign.
I/We have been informed how the information provided will be used and have read the notice on last page.
I/We give consent for my child who is named on page 1 to be referred to Children’s Services by the named person making the referral.
I/We understand that Children’s Services will be requesting information as part of a multi-agency approach to further assess my child’s needs.
I/We would like Children’s Services to contact me before contacting any other agency:
Yes / ☐ / No / ☐
Please specify details:
Click here to enter text.
I have parental responsibility for the child named on page 1
Yes / ☐ / No / ☐
Signed: / Date: / Click here to enter a date.
Relationship to Child / Young Person: / Click here to enter text.
Name / Address / Telephone Number
Click here to enter text. / Click here to enter text. / Click here to enter text.
I have parental responsibility for the child named on page 1
Yes / ☐ / No / ☐
Signed: / Date: / Click here to enter a date.
Relationship to Child / Young Person: / Click here to enter text.
Name / Address / Telephone Number
Click here to enter text. / Click here to enter text. / Click here to enter text.
If no consent is being provided, please explain your reasoning
Click here to enter text.
Young Person’s consent:
How did the child/young person respond when advised that you needed to share information with us in order to protect them from further harm?
Click here to enter text.
Are they competent to and happy to give their consent? / Select a value
Young Persons Consent
I give consent for this referral to be made to Children’s Services.
I have been informed how the information provided will be used and have read the notice on last page.
I understand that Children Services will be contacting other agencies as part of a multi-agency approach to further assess my situation / needs.
I give Children Services permission as part of a s47 investigation and/or single assessment to make contact with other agencies.
I would like Children Services to contact me before contacting any other person or agency:
Yes / ☐ / No / ☐
Please specify details:
Name / Signed / Date
Click here to enter text. / Click here to enter a date.
Are there any worker safety issues?
Yes / ☐ / No / ☐ / Don’t know / ☐
If yes, please give details (this should include dangerous animals)
Click here to enter text.
How information about you will be used
Why organisations keep and share information about you and your child
Swindon Borough Council provides a range of community health, social care and early help services such as, family centres and service and the Youth Engagement Service, as well as Education Support Services. This in an integrated children’s service and is named Children, Families and Community Health Services. It also works with families as part of the troubled families’ national initiative.
This Service holds information on paper and on an electronic database about your family if you are referred to us and if you go onto to receive a service. Once your information is on the database, other professionals within Swindon Borough Council Children, Families and Community Health Services will be able to see which services you are involved with and relevant case information. Staff need this information so they can give the best advice possible and offer support.
Individual case information will not be shared outside of the Children’s Service unless consent has been given, or there is a potential risk of significant harm to a person. However, general demographic data such as name, address, date of birth, and also ethnic group, special educational needs will be shared between organisations that provide public sector services in Swindon and form together as the One Swindon Partnership. These are a range of Health Care providers and Local Council services. Relevant information will also be shared with partners at contact stage through our MASH (multi agency safeguarding hub) which is operated by Swindon Borough Council.
Further information about how organisations use your information can be found at the following website in the document “Contact details and data sharing between organisations”.
If you are concerned in relation to data sharing and would like to opt out of allowing us to share information, you can contact us by:
E-mail:
Or Letter:Data Manager, Children Services, Information and Performance Team, Swindon Borough Council, Civic Offices, Euclid Street, SN1 2JH
Next Steps
The Referral Form should now be emailed using a securely
If you do not have a secure email address, please contact the team so that we can arrange a secure connection for you to send us the referral securely.
If your referral is in relation to a child protection issue, please alert the team on 01793 466903.
The team can be contacted Monday to Thursday 8.30am-4.40pm, and Friday 8.30am-4pm.
If you have a child protection concern for a child outside of these hours, please make contact with our Emergency Duty Service on 01793 436699.
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