Family Referral

Please use this form to refer yourself or a friend or a family to our Home Visiting/Telephone Support/ Groups /Virtual Session Support. If you are making a referral for a family, you must have their consent. We support families within the Borough of Slough and Burnham with at least one child under the age of 5 years unless referring to a specific project.

Main Carer

Please enter details for the main carer and give contact information

Main Carer surname*

Main Carer First Name*

Main Carer Date of Birth

Address line 1*

Address line 2

Town*

County*

Postcode*

Main Telephone Number*

Mobile Telephone Number*

Email

Main Spoken Language

Interpreter Required (Please note this service may not be available)*

Main Carer Ethnicity

Main Carer Disability

Marital Status

Accommodation Type

Family members

Please enter details for all family members, starting with adults and then children (click Duplicate to add another record)

Surname*

First name*

Gender*

Date of Birth

Ethicity

Child/Family Member Disability

Safeguarding for Child (please complete for each child)

Add additional family member

Family needs

To help us assess family needs, please answer the following:

Safeguarding for Family (if there is a current CPP/CIN/Early Help Plan Please note the contact details of key worker under Other agencies working with family*

Domestic Abuse*

Substance abuse*

Any health and safety issues*

Please tell us why you would like Home-Start support:

Caring for children and parenting

(e.g., health concerns, developmental differences, learning difficulties, managing behaviour, setting routines, supporting learning and development, providing healthy balanced diet and physical exercise)*

Parents’ wellbeing and family life (e.g. isolation, anxiety, post-natal depression, physical or emotional health issues, concerns about finances, housing, employment, stress in relationships, difficulty accessing local services, or help withmeal planning/budgeting, improving cooking skills, improving family nutrition and health) *

Please tell us about any other agencies working with this family*

Referrer details:

If referring yourself, please write ‘Self’

Referrer surname

Referrer forename

Job role

Address number and street

Town

Postcode

Direct phone number

email

Person/Organisation Category

If you are referring yourself, where did you hear about us?