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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



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