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Multi-Agency Referral Form (to Childrens Social Care)

Important Guidance Please read this section carefully
This form is to be used to make a referral to Childrens Social Care in relation to a child, or to confirm in writing a referral already made by telephone (all professionals making telephone referrals to Suffolk childrens social services must confirm this in writing within 24 hours). It has been designed to ensure that Childrens Services has enough relevant information about the child or young person, and the concerns which have prompted your referral, to be able to carry out an Initial Consideration, to determine whether or not an Initial Assessment should be undertaken. All referrals will be considered on the basis of the information provided. Not all referrals will result in a service being provided by childrens social care. You should therefore continue to provide existing universal or targeted services whilst awaiting the outcome of your referral.

Safeguarding concern If you believe that a child or young person may be at imminent and significant risk of harm, you should call the Customer First immediately on 0808 800 4005 and then fully complete this form to confirm your referral within 24hrs of your call.
Meeting the Needs of Children and Families in Suffolk Social Care and Common Assessment Framework Thresholds Guidance. This document is intended to assist professionals within the Suffolk childrens workforce to identify suitable responses to needs and issues that they encounter amongst the children, young people and families they are working with. www.suffolk.gov.uk/meetingtheneeds Common Assessment Framework (CAF) - Most referrals to childrens social care will be supported by a completed common assessment. For more information about the Common Assessment Framework and to download a common assessment form, visit: www.suffolk.gov.uk/caf For general guidance on safeguarding and when to make a referral to Childrens Social Care, you are advised to consult the Suffolk Safeguarding Children Board guidance, available on their website: www.suffolkscb.org.uk If you are working with a child or young person for whom a Common Assessment (CAF) has already been fully completed, you can attach the completed CAF and complete Sections A to C only. It is your responsibility to ensure that all of the basic information required is included as part of your referral, either on this form or in the completed CAF. Failure to do so will cause delay for the family.

WARNING
If you are sending this document electronically and are not in a secure network with Suffolk County Council (i.e. your email account does not end in @suffolk.gov.uk, you must ensure that this document is password protected and sent as an email attachment. You should then telephone Customer First on 0808 800 4005 to inform us of the password so that we can open it. If you have any queries about this, please do not hesitate to contact us. Childrens Social Care cannot take responsibility for sensitive information sent to it from outside its secure network. You should email this form to customer.first@suffolk.gov.uk
FOR OFFICE USE ONLY

Date received:

(dd/mm/yyyy)

CareFirst ID: (dd/mm/yyyy)

I have contacted the referrer and acknowledged receipt on: Name: I have contacted the referrer and advised that a) formal referral to Childrens Social Care has been processed b) Information/advice given on CAF/TAC/Local support

Designation: . Name: Designation: .

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Section A Basic referral details (to be completed in all cases)

Date of referral: This is a: Childs name: / / Given name: (DD/MM/YYYY) (date) Family name: Yes New referral, or Confirmation of a referral I made by telephone on No

Is / are the parent(s) / carer(s) aware of the referral?

Permission should generally be sought from an adult with parental responsibility for the child /young person before passing information about them to Childrens Social Care, UNLESS seeking permission would place the child at risk of significant harm. If a child or young person is at immediate risk of significant harm, the referral to Childrens Social Care SHOULD NOT BE DELAYED whilst parental permission is sought. Do you consider the child or young person you are referring to be at risk of significant harm? Is the child/young person aware of referral? Yes Yes No No

If you have not sought consent to refer and/or share information, please state clearly below your reason why. Similarly, if you have sought consent and this was not given but you are nonetheless submitting a referral, please state why:

Section B Referrer details (to be completed in all cases)

Referred by (name): Agency: Address: Telephone: Mobile telephone: Fax: Email address:

Section C Summary of reason for referral (to be completed in all cases)

Please state clearly the reason why you have made this referral. If you have indicated that any child (or children) may be at risk of significant harm you need to tell us how you have come to your view and detail any significant incidents or events that support your view (the box will expand as you type into it)

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If you are working with a child or young person for whom a CAF (Common Assessment Framework) HAS BEEN FULLY COMPLETED, YOU DO NOT NEED TO COMPLETE FURTHER SECTIONS. Instead, attach the completed CAF and any recent Delivery Pan and Review documents. It is your responsibility to ensure that all of the relevant information required is included as part of your referral, either on this form or in the completed CAF. Failure to do so will cause delay for the family.

Tick this box to let us know that you are attaching a completed CAF so that we can make sure the document is attached. Is this a Step up from a Team Around the Child (TAC)? Yes No

Complete the following Sections D to I only if a CAF has not been fully completed (and attached) for the child or young person whom you wish to refer to Childrens Social Care.

Section D Child or Young Persons details

If you are referring more than one child, please complete this for one of the children in detail. List the other children in section H. Family name First name(s) Female (DD/MM/YYYY) Unborn

DOB or expected date of delivery Gender Male Address: Post Code: Telephone:

Child/young persons first language or preferred means of communication: Is an interpreter/signer required? Yes Current address (if different from above) Post Code Telephone No

No

Is the child/ young person disabled? Yes

No

Is the child/ young person privately fostered?* Yes

*A private fostering arrangement is essentially one that is made privately (that is to say without being brought about by a local authority) for the care of a child under the age of 16 (under 18, if disabled) by someone other than a parent or close relative, with the intention that it should last for 28 days or more. Private foster carers may be from extended family such as a cousin or great aunt. But a person who is a relative under the Children Act 1989 i.e. a grandparent, brother, sister, uncle or aunt (whether of full blood or half blood or by marriage) or a step-parent will not be a private foster carer. A private foster carer may be a friend of the family, or the childs friends parents or someone unknown who is willing to privately foster a child.

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Please tick below to describe the child or young persons ethnicity Caribbean African Black African Somali Any other Black background Indian Pakistani Bangladeshi Any other Asian background White British White Irish Any other White background White & Black Caribbean White & Black African White and Asian Any other Mixed background Chinese Any other Ethnic Group Turkish Kurdish

If other, please specify: Further details regarding child/young persons ethnicity: Child/young persons religion:

Child/young persons nationality (if not British):

NB: EU Citizens are not required to register with the Home Office Nationality: Asylum seeking Home Office registration number: Refugee status

Immigration status:

Exceptional leave to remain

Section E Services working with this child

G.P. Name Address Post code Telephone number Health Visitor name Address Post code Telephone number Childrens Centre /Nursery /School name Address Post code Contact person Designation/role Telephone number Other agency name Address Post code Contact person Designation/role Telephone number

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Lead Professional (if applicable) Address Post code Contact person Designation/role Telephone number

Section F Detailed reason for referral

What has led to this unborn baby / infant / child being referred? How do you consider Childrens Social Care to be able to meet the needs of the child(ren) you are referring or to address any immediate welfare concerns? Please indicate if any child(ren) have special needs. Please consider the Meeting the Needs guidance (web link) and the Assessment Framework Triangle shown below to assist you to consider any identified areas of need or welfare concerns.

1.

Development of unborn baby, infant, child or young person Health, behaviour, family, relationships, etc.

2.

Parents and carers safety and protection, emotional warmth, stimulation, etc.

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3. Family and environment housing, neighbourhood, extended family, support networks, community resources, etc.

4.

Other

Section G Parent/Carer details

Name and date of birth (if known) Is an interpreter/signer required? Relationship to child / young person Ethnicity First language Father Yes No Yes Father: Yes No Yes No No Parental responsibility? (yes / no)

Mother Yes No Other main carers (please specify name):

Are any of the main carers disabled? Mother: Yes No Other main carers (please specify name):

Section H Household details

If you are referring more than one child, please complete details of one of the children in detail in Section F (above). List the other children here in Section H. Please list below the names and details of all children and adults who are currently residing with the child or young person. Tick if you are also referring this child / young person

Family name

First name

DOB / age

Relationship to child / young person

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Section I wider family network

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Please list below the names and contact details of any other family members or significant adults in relation this child or young person: Name Relationship Address Postcode Contact number Any additional information: Name Relationship Address Postcode Contact number Any additional information:

We will contact you and acknowledge receipt of the Childrens Social Care Referral Form within one working day.

Resources and useful contact details.

Customer First Postal address: Customer First, Customer Service Direct, PO Box 771, Needham Market, Ipswich, IP6 8WB Telephone: 0808 800 4005 Email: customer.first@suffolk.gov.uk Thresholds Guidance: http://www.suffolk.gov.uk/meetingtheneeds Common Assessment Framework: http://www.suffolk.gov.uk/caf Suffolk Safeguarding Children Board: http://www.suffolkscb.org.uk/

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