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Professionals Referral Form

The targeted support you can refer families to via this referral form includes:

1:1 Family Support

Parenting Courses

Domestic Abuse Recovery Programmes

For details of the services and referral criteria please

download this A4 Information Sheet

All referrals for our targeted support services can be completed on this form and the EYA Family Services Panel will assess the referral and place it within the correct service or programme to meet the family’s needs.

If you wish to discuss a case, please contact us via Lewisham.Secure@eyalliance.org.uk and a member of the Family Service Department Team will contact you.

Please note – WE CAN ONLY PROCESS YOUR REFERRAL IF:

SECTION C is completed if requesting a Domestic Abuse Recovery programme or if the family has experienced current or historical domestic abuse
SECTION D must be fully completed to comply with GDPR regulations

Please refer to our Referral Guidance document for more information.

For urgent child protection referrals, contact the MASH on 020 8314 9181. If you think a child or young person may be in immediate danger, call 999 or contact your local police on 101.

Professionals Referral Form (1)

"*" indicates required fields

Step 1 of 5

SECTION A: REQUIRED INFORMATION ABOUT THE REFERRER and the FAMILY BEING REFERRED

REFERRER’S DETAILS

Name of Professional making the referral*

Organisation / Team & Role*

Telephone Number

Email*

PARENT/CARER*

FIRST NAME

SURNAME

GENDER IDENTITY

RELATION TO CHILD

DATE OF BIRTH

CPP CIN

ETHNICITY

RELIGION

ANY OTHER SIGNIFICANT MEMBER OF THE HOUSEHOLD OR FAMILY

FIRST NAME

SURNAME

GENDER IDENTITY

RELATION TO CHILD

DATE OF BIRTH

SCHOOL

CPP CIN

ETHNICITY

RELIGION

CHILD (Please list all children in the family)*

FIRST NAME

SURNAME

GENDER IDENTITY

RELATIONSHIP TO PARENT/CARER

D.O.B

SCHOOL

CPP/CIN

ETHNICITY

RELIGION

NHS NUMBER

Use the plus button at the end of the line to add more children

DO ANY MEMBERS OF THE FAMILY HAVE A PHYSICAL OR MENTAL HEALTH NEEDS? Please state below

Address and Postcode of Family*

Landline

Mobile

Is it safe to contact?

ARE ANY OF THE FOLLOWING PROFESSIONALS INVOLVED WITH THIS FAMILY?

(please tick all that apply)

Social Worker

Early Help/Family Thrive Practitioner

Health Visitor/Team

Police Officer

IDVA or IGVA

CAHMS

Other professional currently involved in supporting this family (please tick)

Name and contact details of Social Worker

Name

Tel

E-Mail

Name and contact details of Early Help/Family Thrive Practitioner

Name

Tel

E-Mail

Name and contact details of Health Visitor/Team

Name

Tel

E-Mail

Name and contact details of the Police Officer

Name

Tel

E-Mail

Name and contact details of IDVA or IGVA

Name

Tel

E-Mail

Name and contact details of CAHMS

Name

Tel

E-Mail

Name and contact details of other professional currently involved in supporting this family (MAX 6)

Name

Tel

E-Mail

SECTION B:
REFERRERS DETAILS

TYPE OF SERVICE ARE YOU REQUESTING?
Please click on this link for information and eligibility criteria
For more details about each service and programme please click on the following links.
FAMILY PRACTITIONER SERVICE
DOMESTIC ABUSE RECOVERY SERVICE
INCREDIBLE YEARS PARENTING PROGRAMME
POSITIVE PARENTING PROGRAMME - TRIPLE P

Eligibility Criteria*

I have read and understood the eligibility criteria

Which service(s) are you requesting? (Please tick all that apply)*

Family Practitioner Service

Domestic Abuse Recovery Service

Incredible Year Parenting Programme

Positive Parenting Programme - Triple P

WHAT HAS HAPPENED RECENTLY TO THIS CHILD/FAMILY THAT HAS LED TO YOU MAKING THIS REFERRAL?*

WHAT SPECIFIC INTERVENTION ARE YOU REQUESTING FROM OUR SERVICE? PLEASE EXPLAIN WHY YOU CONSIDER US TO BE THE APPROPRIATE SERVICE FOR THIS FAMILY?*

HAVE YOU PROVIDED ANY CONTACT, SUPPORT, OR INTERVENTION?*

Yes

Please list details here:*

Have you explored historical or current domestic abuse with the family?*

Yes

Is the family currently experiencing domestic abuse?*

Yes (please fill in Section C)

Has the family experienced domestic abuse historically?*

Yes (please fill in Section C)

SECTION C: FOR REFERRALS FOR DOMESTIC ABUSE RECOVERY PROGRAMMES AND/OR WHERE CURRENT OR HISTORIC DOMESTIC ABUSE HAS BEEN EXPERIENCED.

Please click on this link for information and eligibility criteria

Note: domestic abuse programme attendance must not be mandated as a statutory response. Both Programmes are consent-based and the victim/survivor must agree to participate and be ready to do so, as these programmes are RECOVERY programmes only.

ABOUT THE ABUSE

Is this family known to MARAC

DASH RIC Score

Professional Judgement

Have they experienced any of the following?*

Physical Abuse

Stalking / Harassment

Financial Abuse

Emotional Abuse

Honour based violence

Coercive control

Sexual Abuse

Psychological Abuse

Forced marriage

Tech Abuse

Additional notes:

Is the relationship ongoing?*

Yes

Don't Know

If no, how long was the relationship?

If no, when did the relationship end?

Does the perpetrator/alleged perpetrator still reside in the family home?*

Yes

Don't Know

If no longer in the relationship with the alleged perpetrator, is the client currently in a new relationship?

Yes

How has the child/children been impacted by the abuse?

INFORMATION ABOUT THE PERPETRATOR/ALLEGED PERPETRATOR (IF KNOWN)

Name

Relationship to client:

Address:

DOB:

DD slash MM slash YYYY

Does the perpetrator / alleged perpetrator have contact with the children?

Yes

Is there a non-molestation order in place?

Yes

Is there a prohibitive steps order in place?

Yes

Is the perpetrator/alleged perpetrator known to probation services?

Yes

Are there any licence/bail conditions or current proceedings taking place in relation to the Domestic Abuse?

Yes

If yes, please provide details:

If there is more than one alleged perpetrator, please provide additional details below:

SECTION D:
FAIR PROCESSING AND CONSENT FORM

IF THE PARENT HAS NOT SIGNED THIS FORM, PLEASE CONFIRM AT THE BOTTOM OF THIS SECTION THAT THE PARENT HAS GIVEN VERBAL CONSENT FOR THIS REFERRAL AND TO DATA BEING PROCESSED AND RETAINED NOTE: WE offer consent-based services only, so a referral will NOT be accepted if verbal consent is not clearly shown.

Here at Lewisham Children and Family Centres we take your privacy very seriously with your consent we will process, retain and store your personal data on behalf of the London Borough of Lewisham in line with the General Data Protection Regulation (GDPR) (EU) 2016/679. Your personal data and contact details will not be shared with any other third party or organisation but may be shared with other Children and Family Centres, and other partnership organisations. You have the following rights regarding your personal data:

The right to withdraw consent at any time
The right to request your personal data is deleted
The right to access to your personal data

For more information regarding the use of your personal data please see www.lewishamcfc.org.uk or make a request to: Lewisham.Secure@eyalliance.org.uk or

Early Years Alliance, Camelot Centre, 50 Meliot Road, London, SE6 1RY

and a copy of the policy will be sent to you.

Please Tick Consent*

I understand that by providing my consent I am confirming I understand how and why my personal data is used and give permission for Lewisham Children and Family Centres to store and update my personal details.

I am a Parent Tick*

I am a parent/legal guardian of a child/children under the age 16 and give consent for Lewisham and Children Family Centres to store and use my child/children’s personal data for the purposes of the service.

I give permission*

I give permission to Lewisham Children and Family Centres and any relevant partner organisation to contact me regarding services available and my access to them by:

Phone

Mail

PLEASE SELECT 'YES' TO ENABLE US TO PROCESS YOUR REFERRAL AS SOON AS POSSIBLE

PLEASE CONFIRM THAT THE PARENT HAS GIVEN VERBAL CONSENT FOR THIS REFERRAL.*

IF THE PARENT HAS NOT SIGNED THIS FORM, PLEASE CONFIRM BELOW THAT THE PARENT HAS GIVEN
VERBAL CONSENT FOR THIS REFERRAL AND TO THEIR DATA BEING PROCESSED AND RETAINED.
NOTE: WE offer consent-based services only, so a referral will NOT be accepted if verbal consent is not clearly shown.

VERBAL CONSENT HAS BEEN GIVEN

Date Consent Given:*

DD slash MM slash YYYY

REFERRER’S NAME:

REFERRER’S NAME:*

Please type name

Date:*

DD slash MM slash YYYY

Comments

This field is for validation purposes and should be left unchanged.

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This local website is managed by the Early Years Alliance.

The Early Years Alliance is the trading name of the Pre-school Learning Alliance.

Registered as a limited company in England and Wales (no. 4539003)
Registered as an educational charity with charity number 1096526
Authorised and regulated by the Financial Conduct Authority
VAT Registration Number: GB 830 472 251
Registered office: 50 Featherstone Street, London, EC1Y 8RT

Welcome to the Early Years Alliance Lewisham Services Website

Professionals Referral Form

Professionals Referral Form (1)

SECTION A: REQUIRED INFORMATION ABOUT THE REFERRER and the FAMILY BEING REFERRED

REFERRER’S DETAILS

ARE ANY OF THE FOLLOWING PROFESSIONALS INVOLVED WITH THIS FAMILY?

SECTION B: REFERRERS DETAILS

SECTION C: FOR REFERRALS FOR DOMESTIC ABUSE RECOVERY PROGRAMMES AND/OR WHERE CURRENT OR HISTORIC DOMESTIC ABUSE HAS BEEN EXPERIENCED.

INFORMATION ABOUT THE PERPETRATOR/ALLEGED PERPETRATOR (IF KNOWN)

SECTION D: FAIR PROCESSING AND CONSENT FORM

REFERRER’S NAME:

SECTION B:
REFERRERS DETAILS

SECTION D:
FAIR PROCESSING AND CONSENT FORM