UBARNARDO’S JIGSAW

CONFIDENTIAL INFORMATION

REFERRAL FORM

ALL information provided will be shared with the family and Westlea staff
Name of Referrer:
Email Address: / Date Of Referral:
FAMILY COMPOSITION
Last Name / First Name / M / F / Relationship / DoB / Nursery, School or College, Occupation / Ethnic Origin*
MaleFemale / See List Below1A1B1C1D2A2B2C34A4B4C56A6B6C7
MaleFemale / See List Below1A1B1C1D2A2B2C34A4B4C56A6B6C7
MaleFemale / See List Below1A1B1C1D2A2B2C34A4B4C56A6B6C7
MaleFemale / See List Below1A1B1C1D2A2B2C34A4B4C56A6B6C7
MaleFemale / See List Below1A1B1C1D2A2B2C34A4B4C56A6B6C7
MaleFemale / See List Below1A1B1C1D2A2B2C34A4B4C56A6B6C7
*ethnic origins
Asian or Asian British
1A – Bangledeshi
1B – Indian
1C – Pakistani
1D – Other Asian / Black or Black British
2A – African
2B – Caribbean 2C – Other
Other
5 – Other Ethnic Grp / Chinese
3 – Chinese
White
6A – British
6B – Irish
6C – Other White / Mixed
4A – Asian & White
4B – Black African & White
4C – Black Caribbean & White
7 – Not Disclosed
Home Address:
/ Contact no:
Email address:
Westlea Property: YesNo
Safe Register? Yes / NoYesNo / Other address if not living with family:
/ Contact no:
Westlea Property: YesNo
ANY OTHER SIGNIFICANT FAMILY/FRIEND
Last Name / First Name / Relationship / / / 
ANY INDIVIDUAL NEEDS? e.g. Religious/Language/Interpreter/Disability/Dietary
HOUSING OFFICER:-
Email address:
REFERRAL DETAILS
Tell us about the issues which the family are facing at the moment.
(why you are making this referral now)
What difficulties relate to
  • Relationships within the family?
  • To financial or practical matters?
  • Lack of support from others?

What needs to change to help the family?
What support are you requesting
  • From Jigsaw (Wiltshire) team?
  • From other agencies?

What is your role/ what support are you providing?
Any other relevant information?
Recording Policy: Referrer must inform the family that information provided about them will be held on the Barnardo’s secure computer system. Information will be held in accordance with the Data Protection Act requirements and will not be shared without the person’s consent, unless there are concerns for the safety and wellbeing of a child or vulnerable adult. Individuals wishing to view this data should write to the Jigsaw manager. I consent to my name and contact details being shared with Westlea Housing Association.
Signature of parent/ Carer: Date:
Signature of parent/ Carer: Date:
Signature of Referrer: Date:
Date Referrer discussed this referral with the family:Date:
Jigsaw (Wiltshire)Worker taking referral (if appropriate): Date:

Please send completed Referral Forms to

Jigsaw (Wiltshire), Brook Street, Chippenham, Wiltshire. SN14 0JE

If you require further information, please contact the office on 01249 463907.

Further information and additional forms are available from our website, HUU

For office use only:

Barnardo’s worker checklist
Copy sent to Westlea Housing officer? / YesNo
Family registered with project? / YesNo
Feedback to family? / YesNoNot Applicable
CAF? / YesNo
Data Protection / Confidentiality? / YesNo
1.2.06 Improved behaviour / 6.1.04 Positive socialisation with peers
1.2.19 Improved self esteem / 7.1.01 Contribute to planning and decision making
2.1.05 Able to report safety concerns/ complaints / 7.1.05 Views and opinions voiced and acted on
2.1.08 Reduction in level of risk/ harm / 9.2.03 Parents supported in accessing employment, education or training
4.1.04 Positive/ improved family relationships / 9.3.01 Secure tenancy
4.1.05 Stable and secure family environment / 9.5.02 Improved resource management by parents
4.1.20 Prevent admission into care / 9.5.03 Full receipt of entitlements/grants

Barnardo’s Registered Charity Nos 216250 and SC037605

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