Lambeth Children’s Services First Response Team Multi-Agency Referral Form

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Lambeth Children’s Services First Response Team

Multi-Agency Referral Form

CONFIDENTIAL

Notes for use: Please complete this form electronically; the text boxes will expand to fit your text.

The completed form contains personal data to be protected and processed in line with the Data Protection Act 1998.

AGENCY COMPLETING:

Name of Worker:		Date of Referral:
Agency:		Role of person completing referral:

FAMILY DETAILS:

Child

Forename(s):		Ethnicity: *(please see end for full codes)**
Surname(s):		Date of Birth / EDD:
Gender:		Interpreter required:
Preferred Language:		NHS No.
Disability:		School Unique Pupil Number:
Home address		Name of GP/ Practice:
FAMILY INFORMATION:
Name:	DOB:		Gender: (M/F)	Relationship to the child:

Overview of Agency

Involvement with child/family including information of attendance/engagement with your service:

Has a CAF been completed	Yes		No
If yes, please attach to this referral form

What are you worried about?

please state the name of the child if you have any specific concerns about one particular child.

Past Harm to children

Action/behaviour-who what where when; severity; incidence and impact

Future Danger for Children

What are you worried is going to happen to the child if the current situation does not change? - related to past and future harm

Complicating Factors

Factors which make the situation more difficult to resolve

What is working well?

Existing Strengths

Existing Safety /Protection: The strengths sustained over time, directly related to the danger.

What needs to happen?

Future safety/protection/safety goals (When will things be safe enough, what do you want to see parents/carers doing to make the child safe)

Parent and child’s views

Next Steps

What can you /your agency contribute to a plan to keep the child safe? What are the next steps to be taken to achieve the safety goals?

Signature of person completing referral:
If applicable - Signature of designated CP person/manager for Agency authorising the report:
Every effort should be made to share this referral with those with Parental Responsibility if this is appropriate to do so. In circumstances where this is not possible, please state reason & make attempts to inform of content verbally:
Have those with Parental Responsibility viewed/had verbal feedback of this referral? If possible, please obtain signatures of those with legal Parental Responsibility who have viewed/had verbal feedback of the report:	No Yes How? …………………………………………………………… …………………………………………………………… Date:

It is the responsibility of all agencies who are making enquiries and/ or making referrals about child/ren to inform the parents/ carers or those with parental responsibility that they are making a referral to Children Social Care.
The referral must be sent to First Response Team (FRT) via secure email duty.manager@lambeth.cjsm.net

or with password protection to dutymanager@lambeth.gov.uk

Please code ethnicity using the following tables:
White

White British	WBRI
White Irish	WIRI
Traveller of Irish Heritage	WIRT
Any other White background	WOTH
Gypsy/Roma	WROM

Mixed

White and Black Caribbean	MWBC
White and Black African	MWBA
White and Asian	MWAS
Any other Mixed background	MOTH

Asian or Asian British

Indian	AIND
Pakistani	APKN
Bangladeshi	ABAN
Any other Asian background	AOTH

Black or Black British

Caribbean	BCRB
African	BAFR
Any other Black background	BOTH

Other Ethnic Groups

Chinese	CHNE
Any other ethnic group	OOTH
Refused	REFU
Information not yet obtained	NOBT

Lambeth MARF 05.01.2015