H-S Family Code…………………

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					H-S FAMILY CODE                             VOL CODE                         H-S OFFICE USE ONLY
FIRST VISIT                                 LINKED                           DATE W/D

Home-Start North Lincolnshire - Family Referral Form
VERSION 2009/1 (27/3/09)
(This form will be held in confidence but may be shared with the family if requested)

All referrals must be made with the consent of the family who must have at least one child under 5.
Have you discussed this referral with the family prior to completing this form?            YES/NO

Title:                 Name:                                                        D o B:
Title:                 Partner’s name:                                              D o B:
Address:                                                                            Postcode:   DN
Tel No:                                                                             Date of Referral:
Ethnic origin:                                                                      Employed?        Y / N*
Marital status:                                                                     Pregnant at referral? Y / N*
Do they class themselves or a child as having a disability?              ADULT Y / N*        CHILD Y / N*
Details of disability (if applicable)
                                    *Please tick/circle appropriate answers above

If any family members are experiencing mental health issues, please give details below:-
………………………………………………………………………………………………………………
NAME OF CHILD              SEX       DATE OF          ON CPR         REF AFTER          CHILD ON        WITHDRAWN
                           M/F        BIRTH                            CASE               CARE           FROM CPR
                                                                    CONFERENCE           ORDER
                                                     YES / NO         YES / NO          YES / NO
                                                     YES / NO          YES / NO         YES / NO
                                                     YES / NO          YES / NO         YES / NO
                                                     YES / NO          YES / NO         YES / NO
                                                     YES / NO          YES / NO         YES / NO
Subsequent births




Has a Common Assessment Form been completed for any of the above? YES / NO (Please highlight for
whom)*(If you have answered “YES” to the above – please attach a copy for our information)*

Has a “CIN” or “CWAN” meeting taken/going to take place? YES / NO

Referred by:                                                 Status:
Agency:                                                      Tel No:
Address
Please complete the following if known or involved with the family:-
Family Doctor                                                     Tel No
Health Visitor                                                    Tel No
Social Worker                                                     Tel No
CPN                                                               Tel No
Any other agencies                                                Tel No
                                                                  Tel No
Are there any issues around Health & Safety that we need to consider when placing a volunteer
with this family? (For example, Domestic Violence or large animals?)
So that we may offer the family the most appropriate support, and match the most suitable volunteer,
please complete the following table. Please note that we do not operate a “points system”. Families will not
be prioritised on the basis of how many boxes are ticked. Please add any background information that you
think we would find useful on an extra sheet.

Home-Start North Lincolnshire’s policy on Confidentiality is that all personal information about parents
and families is treated as confidential, to be discussed only as necessary with the co-ordinator in support of
the volunteer and to assist the family. Any disclosure of the confidential information to any other person may
only be undertaken with the expressed permission of the parents for the purpose of assisting the family,
except where it is considered necessary for the welfare and protection of a child when information shall be
shared with the appropriate authority.
                  “I hope that by supporting this family, Home-Start will help to…..”
Office                                                  TICK      IF TICKED, PLEASE TELL US WHY THIS IS A NEED AND
use                                                      IF
                       CATEGORY                                        HOW A VOLUNTEER MIGHT BE ABLE TO HELP
only                                                    REQ
1        Reduce the parent’s isolation

O3
2        Increase the family’s access to other
         services/facilities
O4
3        Improve the parent(s) emotional
         health/ well-being
O1
4        Develop parental self esteem
O2
5        Improve the health/physical well-
         being of the parent(s)
O1
6        Improve the health/physical well-
         being of the child(ren)
O1
7        Improve the child(ren)’s emotional
         health/ well-being
O1
8        Support the parent(s) to manage the
         child(ren)’s behaviour
O2
9        Increase the involvement of the
         parent(s) in the development of their
O3       child(ren)
10       Reduce the stress associated with
         family conflict
O2
11       Improve the parents’ ability to
         manage the household on a day to
O2       day basis
12       Improve household budgeting
O5
13       Help with the extra work caused by
         multiple birth/multiple children under
O2       5 years old
14       Other (please explain)


15       Reduce the need for the intervention
         of other services
O4

           All completed forms should be returned to the Home-Start office (address below):-
                   103a Frodingham Rd, Scunthorpe, DN15 7JU (01724) 858433/4

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Description: H-S Family Code…………………