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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)
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, providinghealthybalanced dietand 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 with meal 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?