Making a referral

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CS700/Oct 2014
Multi-agency referral form to Surrey Children’s Services

This form is to be used when making a referral which requires a response from Surrey Children’s Service. If you are unclear whether to make a referral, please discuss this with your Safeguarding lead and or the Contact Centre before completing this form

Referral Completed by: (details of person taking the referral)
Name of referrer:		Job title:		Agency:
Address: Email: Telephone:
Date of Referral:	Time of referral:		Date and time MARF form completed:

1. CHILD/YOUNG PERSON DETAILS/SIBLING DETAILS
Last Name	First Name	Age/DOB/ EDD	M/F	Ethnicity/ Language	Religion	Address and telephone number



2. HOUSEHOLD DETAILS (including extended family)
Last Name	First Name	Age/DOB/EDD	M/F	Ethnicity/ Language	Relationship to child	Address and telephone number




Give details of principal carers and those with Parental Responsibility (if their address is different from the child):
Last Name	First Name	Age/DOB/EDD	M/F	Ethnicity/ Language	Relationship to child	Address and telephone number

Are there any communication/interpreting needs for the child and/or family?

Does the child and/or family have a disability or special needs?

3. Other professionals involved (to include GP, school and details of any voluntary agencies involved)
Name	Job Title	Address	Telephone/email

4. Reason for Referral
What was the date and time of presentation? Was the child/young person present? YES NO If NO, please give details of where the child was at the time of referral and who they were with:
Why are you worried about this child/these children?
What has happened? What are these concerns based on? Why is Children’s Services involvement needed now?
What are the known views of parents/child?
5 . Previous involvement
Has an Early Help Assessment been completed? No Yes , please attach If No, please say why not:
What services have already been offered by your agency and/or other agencies and what were the outcomes?
Are you aware of any previous social work involvement with this family? YES NO If YES, please give details, including approximate dates:
6. Consent (Please note that parents/carers have to consent to this referral unless obtaining this consent will place the child at further risk of harm)
Have parents/carer(s) given consent for this referral? Yes No	Has the child given consent for this referral? Yes No
If consent has not been obtained, please give reason.
7 . Are there any issues we should be aware of when contacting parents/carers?

Name of referrer: 