REFERRAL AND INITIAL INFORMATION RECORD by BW1JQy

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									                                                                                 SOCIAL SERVICES
                                                                                   DIRECTORATE
                                                                               CHILDREN’S SERVICES

            REFERRAL AND INITIAL INFORMATION RECORD
 (To be used by agencies when making a referral to Social Services – A
     written referral must be made within 48 hours of a verbal referral)

SSD Case Numbers                           Is the parent/carer aware of the referral? Yes      No      Re-referral

Child/Young Person’s name, address and responsible Local Authority
Family name
                                                                    Dob                     Gender
Forenames
Address
Postcode                                                            Tel:
Current address if different from above
Postcode                                                            Tel:
Previous address
Postcode                                                            Tel:
SSD Team                                                    Responsible Local Authority

Child/Young Person’s Principal Carers
Name                                  Relationship to child/young person                      Parental Responsibility
                                                                                              Yes         No
                                                                                              Yes             No

Referred by                                        Agency/rel. to child/young person
Address
Postcode                            Tel:                           Date of Referral:

Child/young person’s religion                            Child/young person’s ethnicity
                                                                        White & Black
Caribbean                  Indian                 White British                                      Chinese
                                                                        Caribbean
                                                                        White &                      Any other
African                  Pakistani             White Irish
                                                                        Black African                ethnic group
Any other                                      Any other                White and
                         Bangladeshi                                                                 Not given
Black background                               White Background         Asian
Any other Asian background                     Any other Mixed background
If other, please specify      Child’s first language                 Parent(s) first language

Is an interpreter or signer required? Yes         No                   Has this been arranged? Yes             No

Other household members (including non-family members)
                                                                                            Relationship
 Surname                   Forename                DoB            Nursery/School
                                                                                            to child




    Revised January 2006                                                                             1 of 3
Significant family members who are not members of child’s household
Name                                                  Name
Relationship                                          Relationship
Address                                               Address
Tel:                                                  Tel:

                                                                            Please give details
                                                               Yes No
Child/young person or other child(ren)/young person(s)                      Name
in family is/has been on a disability register                              Date(s)
                                                                            Name
Child/young person or other child(ren)/young person(s)         Yes No
                                                                            Date(s)
in family is/has been on a child protection register
                                                                            Category
Child/young person or other family member(s) has/have          Yes No       Name
been looked after by a local authority                                      Date(s)


Key agencies (please tick if currently working with the family)
G.P.                              Tel:                       H.V.                                 Tel:
Nursery                           Tel:                       E.W.O.                               Tel:
School                            Tel:                       Police                               Tel:
Y.O.T.                            Tel:                       Other S.S.D.                         Tel:
Community Mental Health           Tel:                       Community Paediatrician              Tel:
School Nurse                      Tel:                       Other                                Tel:
Other                             Tel:                       Other                                Tel:

What supports are currently in place.




       Revised January 2006                                                                              2 of 3
Reason for referral/request for services:
Identify strengths as well as needs
Considering: Parenting capacity, child development,
family and environmental factors

You must state the nature of concern or perceived risk in
as much details as possible




Name of worker (completing this referral)

Signature:
For Social Services use only
Date:
Further Action:
                                                      Referral to other agencies
Provision of information and advice
                                                      (please state which)
Initial assessment (to be completed within
                                                      No further action
7 working days)
Core assessment (to be completed within               Practice note: ensure this referral is collated
35 working days)                                      with previous referrals or files

Name of Social Worker:

Signature                                                                 Allocation Date

Name of Team Manager                                                      Or

                                                                          NFA Date
Signature:                                   Date




   Revised January 2006                                                                      3 of 3

								
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