Family Referral

1 Main Parent/Carer: Please provide the main parent/carer’s details. This is the family member we will be working and communicating with.
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First name*
Surname*
Has the parent/carer given consent for the referral?*
Borough of Residence*
Address*
Postcode*
Main Telephone No.*
Email Address
Date of Birth*
Gender*
Ethnicity
Other Ethnic Background
Main Disability or Health Condition
Other Disability, Physical or Mental Health Condition
Primary Language Spoken*
Other Languages Spoken
Does this family need an interpreter? If yes, please state which language.
Immigration Status
2 Family Circumstances: Please complete this section to help us understand the family’s needs and offer the most suitable support.
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Referral Details:
Please tell us why the family needs Home-Start and what support they require.
Elaborate on the family’s background, circumstances and needs and consider the views of both adults and children, including any strengths (e.g. support network, resilience, stability) and struggles or difficult circumstances, such as:
• Child’s development and behaviour, parenting needs, multiple birth/children under 5, child protection, CiN
• Isolation, lone parent, self-esteem, teenage pregnancy
• Child/parent physical/mental health (e.g. disability, illness, SEN, PND)
• Running of the home (e.g. finances, immigration, family conflict, substance misuse, use of/access to services, lack of English, housing – Insecure, inappropriate etc.*
Risk Assessment:
Please provide details of any Health & Safety or risk issues for lone-working and home visiting the family, including domestic abuse.
Please explain the circumstances to enable us to process the referral.*
Are there any Safeguarding/Child Protection Concerns for this family?*
If yes, provide the Safeguarding/Child Protection Start date:
Which type of support does the family feel they need most? (We will assess the family’s need for other services at our initial visit):
3 Family Members: Use this section to enter the details of children and other adults in the family. Use the “Add another family members” button, to separately add each child, including unborn, and other adults.
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First name
For unborn children, entre “Unborn” if the name is unknown.*
Surname*
Please state this person’s role in the family*
Date of birth
(If the child is unborn, please leave empty and provide an EDD below)
Child EDD (Expected date of Delivery for unborn child)
Gender
Ethnicity
Other Ethnic Background
Main Disability or Health Condition
Other Disability, Physical or Mental Health Condition
Add another family member
4 Details of person making referral.
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Referrer Full Name and Role*
Referrer Agency Address and Postcode*
Referrer Phone*
Referrer Email*
Referrer Sector*
5 Other agencies
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Health Visitor
Other Agencies Involved

By submitting this form, you are confirming that:

- the information provided is correct to the best of your knowledge
- the referral has been discussed with the family, who have agreed to a referral being made to Home-Start Westminster.
- you as the referrer and the family, agree for your details to be stored in our database in accordance with data protection legislation (see our Privacy Notice).

You understand that we can only accept referrals which have been discussed with and agreed by the family. The information provided in this referral will be held in confidence but may be shown to the family if requested. Where a family has agreed to our support, we will ask them to sign our privacy notice.

You can find our Privacy Notice here for reference.