Referrer Name: Job Title

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Referrer Name:
Job Title:			Date of Referral:
Address:			Fax:
Tel:			Email:

Multi Agency Referral Form: Consideration for Statutory Assessment.
If you consider the child to be at risk of significant harm please make an immediate telephone Referral on 0151 233 3700.

If there is an emergency please contact the Police on 999.

Please email the completed Multi Agency Referral Form to: carelinechildrensservices@liverpool.gcsx.gov.uk

or fax to 0151 225 2275.

Details of child(ren) being referred including siblings.
First Name	Surname		D.O.B			Gender		Ethnicity




Address:					Tel
Childs principal carers.
Full Name		D.O.B		Ethnicity			Relationship to child



Parental responsibility- Please indicate who holds parental responsibility (legal guardian) and provide address and contact number.
Name and Address:				Contact Number:
Is the above the main carer?
Details of key professionals involved e.g. GP, Health Visitor, School.
Name and role of professional Involved.		Contact Number		Address

Do any of the following issues affect the child? If so please provide details within the reason for Referral.
Missing incidents.	Domestic violence.	Drug/Alcohol use.
Mental Health.	Genital mutilation.	Forced marriage
Honour based violence.	Child sexual exploitation.	If the child is at risk of child sexual exploitation please download and complete a CSE1 form and attach along with this MARF. CSE 1 Forms are available to download via www.liverpoolscb.org
Reasons for the Referral- Clearly state the cause(s) for concern. Please be as specific as possible. Please refer to the Levels of Need Framework- to access click on the following link: Responding to Needs Guidance and Levels of Need Framework.

Have you received consent from the parent or those who have parental responsibility to make this referral to Children’s Services? (If not please state the reason why) It is important that the parents are aware of and agree with you making the referral, unless this would place the child at risk of harm. Please Note! You can refer safeguarding concerns without consent.
Are there any special requirements for the child/family? For example an interpreter or signer or any other additional requirements relating to special needs or disabilities.
Feedback to referrer: For office use only.

Liverpool MARF version 9.0: 11.11.2014

Referrer Name:  Job Title

Referrer Name: Job Title