Child Poverty Family Intervention Project

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                             REQUEST FOR SERVICES

1. Referrer Details


Referring Agency

Agency Address

Email Address

Date of Referral

We want to make sure this service is accessible to all families in Bristol. Please answer
questions 4-8 for equalities monitoring purposes.

2. Household      3. Relationship    4.    5.            6. Are      7. Do you       8. Are you    9. Current
Members                              Age   Ethnicity     you a       have a          living with   address incl.
(including                                 (see back     disabled    learning        or            length of stay at
first names)                               page for      person?     difficulty?     recovering    this address &
                                           codes)                                    from          tel. no.

10. Type of accommodation (Please tick)                         7. Are the family facing any legal
                                                                proceedings that threaten their
Temporary                           Permanent                   tenancy?

Local authority             Registered social landlord          Yes

Private rented sector        Owner occupier                     No

11. Is anyone in the household working?

Name                        Occupation                 Part-time (p) Full-time (f)       Temporary /Permanent

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12. Barriers to employment

Drug and alcohol misuse         Domestic violence and abuse         ex offender        Parenting issues
Family debt        Risk of homelessness         Relationship breakdown      Low qualifications
Social exclusion         mental health issues        Intergenerational unemployment
Other (please specify)

Please put brief details below:

13. Briefly describe the work your agency has undertaken with the family:

14. Other services already received by family:

15. What other agencies (including schools) are engaged with the family?

Family member               Agency                       Agency contact               Contact details

16. Wider family /friends or other support:

Names                                  Relationship                      Contact details

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17. Have any of the children in the household had an assessment through a CAF (Common
Assessment Framework) panel?

Yes                        No                          Not Known

Name of child/ren                     Date and location of panel         Name & agency of lead
                                      meetings                           professional

Please attach a copy of the assessment if available.

18. Have any of the children got a child protection plan?

Yes                        No                          Not Known

Full name of child/ren                                   Date of plan & category

19. Have any of the children previously been on the child protection register?

Yes                        No                          Not Known

Full name of child/ren                                   Date of registration & category

20. Other Concerns (please include anything else that you feel might be useful to know about
the family – for instance: mental and physical health issues, parenting issues, discrimination or
crime against the family, teenage pregnancy, child protection issues, relationship between family
members etc.)

21. Risk Assessment (please explain any risk involved in supporting the family, e.g. history of violence or
aggression, drug/alcohol misuse, family pets).

22. What are the extended family’s attitudes to this intervention?

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23. Do the parents/carers recognise the need to change?                    Yes             No

24. Do the parents/carers willing to engage with education, training or employment?
                                                                Yes         No

25. Referrer signature

 Signed                                                                            Date

26. Family signature

                           Agreement to share personal information
In order to make sure this is the right service for your family and to see what resources might be
available to support you, your request for services will be discussed by members of the Child
Poverty FIP Multi-Agency Delivery Group.

The Multi-Agency Delivery Group is made up of representatives from Job Centre Plus, Avon &
Wiltshire Mental Health Partnership, National Health Service, the Anti-Social Behaviour Team,
Probation Service and Children and Young People’s Services.

I/we agree to this referral and to the personal information that I/we have given being shared with
the Multi-Agency Delivery Group.

Signed                                                                            Date

Signature of parent (s) (or person with parental responsibility)

Signed                                                                            Date
Signature of professional

If referral made over the phone, can referrer confirm that this referral has been discussed
with the family? If so, have they agreed to it? Yes              No

The Parent Support Team processes personal data about service users and is a “Data Controller” in
accordance with the Data Protection Act 1998. We process this data to monitor, report on and improve on
the team’s performance.

From time to time the service is required to pass on data to the Local Authority and its contracted agencies,
other Local Authorities, The Department for Children, Schools and Families (DCSF) and to agencies that are
prescribed by law, such as Ofsted, the Department of Health (DH) and Primary Care Trusts (PCT). All
personal data will be held securely and in accordance with the Data Protection Act 1998.

If you have any questions about the use of this data or wish to access your personal data, or that of your
child, then please contact the Parent Support Project Manager in writing.

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                                REFERRAL CRITERIA FOR FAMILIES

   1. All parents/carers must be unemployed and/or be working in low paid, low skilled,
      part-time and/or temporary jobs

   2. All parents/carers will be grappling with a number of longstanding intergenerational
      barriers to employment, such as:
          - domestic violence and abuse
          - drug and alcohol misuse
          - mental health issues
          - family debt
          - housing issues – including homelessness or risk of homelessness
          - relationship breakdown and conflict
          - ex offender
          - low qualifications
          - parenting issues
          - social exclusion

   3. All parents/carers will able to demonstrate both motivation to ‘change’ and a level of
      stability e.g. evidence of wider family or other support; evidence of engagement and
      co-operation with local support agencies; positive reason for achieving change.

                                          EQUALITIES MONITORING codes

White                                  Asian or Asian British               BC Chinese
WB British                             AB Bangladeshi
WI Irish                               AI Indian                            Other:
WE other European                      AP Pakistani                         A Any other Asian background
                                                                            B Any other Black background
Dual Heritage                          Black or Black British               M Any other mixed background
WA White and Asian                     BA African                           W Any other White background
WBA White and Black African            BS Somali African                    Please state on the form.
WBC White and Black                    BC Caribbean

Office use only                                            Please return this form to:
Date received
                                                           Sunny Sumal, Manager
Method of receipt Post           Email                     Child Poverty Family Intervention Project
                                                           The Park
Phone           Reference No
                                                           Daventry Rd
                                                           Bristol BS4 1DQ
                                                           Tel 0117 9039750
Date of allocation

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Description: Child Poverty Family Intervention Project