Children's Referral Form

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Verification

I wish to remain anonymous

We would like to tell the person(s) that you have raised concerns about who made a referral to us, so that they can understand why the concern was raised. HOWEVER, we will not share your details without your permission. More information about how Doncaster Children's Services Trust handles personal information can be found here: Privacy Policy

Following the referral, we will only be able to update you with any outcomes if you give us authority to disclose your identity to the person(s) you have raised concerns about (so they know who information about our work with them is being shared with) and if we have permission from the person(s) you have raised concerns about to do so.

Please complete your details below.

Forename

Surname

Telephone number

About you

Professionals only

What type of referral are you making?

Job title

Name of organisation

Address of organisation

As you are making a referral to social care you must have verbal or written consent to continue this referral online, or provide your reasons for dispensing with consent. The online form should not be used for immediate safeguarding concerns, please call us on 01302 737033.

Please confirm the name of the person who gave consent and the date consent was obtained for this referral. If consent has not been obtained please explain why you have decided to dispose with consent.

Consent received from?

Upload consent

Acceptable file types are pdf, gif, doc, docx, png, tif, jpg and jpeg.

Please complete the details below.

1st parent/carer name

1st parent/carer - Date consent sought

YYYY

2nd parent/carer name

2nd parent/carer - Date consent sought

YYYY

All parents/ carers understand that information will be shared with services where appropriate.

Are you making this referral for support from Child and Adolescent Mental Health Services (CAMHS)?

GP name

GP surgery

Height

Weight

BMI

Allergies

Medication

Please complete the details below for the child you are making a referral for.

Name

Gender

DOB or approximate age

Address

Ethnicity

First language

Do you need to add another child?

Please complete the details below for the second child you are making a referral for.

Name

Gender

DOB or approximate age

Address

Ethnicity

First language

Do you need to add another child?

Please complete the details below for the third child you are making a referral for.

Name

Gender

DOB or approximate age

Address

Ethnicity

First language

Do you need to add another child?

Please complete the details below for the forth child you are making a referral for.

Name

Gender

DOB or approximate age

Address

Ethnicity

First language

Do you need to add another child?

Please complete the details below for the fifth child you are making a referral for.

Name

Gender

DOB or approximate age

Address

Ethnicity

First language

Do you need to add another child?

Please complete the details below for the sixth child you are making a referral for.

Name

Gender

DOB or approximate age

Address

Ethnicity

First language

Do you need to add another child?

Please complete the details below for the seventh child you are making a referral for.

Name

Gender

DOB or approximate age

Address

Ethnicity

First language

Do you need to add another child?

Please complete the details below for the eighth child you are making a referral for.

Name

Gender

DOB or approximate age

Address

Ethnicity

First language

Do you need to add another child?

Please complete the details below for the ninth child you are making a referral for.

Name

Gender

DOB or approximate age

Address

Ethnicity

First language

Do you need to add another child?

Please complete the details below for the tenth child you are making a referral for.

Name

Gender

DOB or approximate age

Address

Ethnicity

First language

Please complete the details below

1st parent/carer name

Gender

DOB or approximate age

Relationship to child

Ethnicity

First language

Telephone number

Email address

Address

Add another

Please complete the details below

2nd parent/carer name

Gender

DOB or approximate age

Relationship to child

Ethnicity

First language

Telephone number

Email address

Address

Add another

Please complete the details below

3rd parent/carer name

Gender

DOB or approximate age

Relationship to child

Ethnicity

First language

Telephone number

Email address

Address

Add another

Please complete the details below

4th parent/carer name

Gender

DOB or approximate age

Relationship to child

Ethnicity

First language

Telephone number

Email address

Address

Add another

Please complete the details below

5th parent/carer name

Gender

DOB or approximate age

Relationship to child

Ethnicity

First language

Telephone number

Email address

Address

Add another

Please complete the details below

6th parent/carer name

Gender

DOB or approximate age

Relationship to child

Ethnicity

First language

Telephone number

Email address

Address

Add another

Please complete the details below

7th parent/carer name

Gender

DOB or approximate age

Relationship to child

Ethnicity

First language

Telephone number

Email address

Address

Add another

Please complete the details below

8th parent/carer name

Gender

DOB or approximate age

Relationship to child

Ethnicity

First language

Telephone number

Email address

Address

Add another

Please complete the details below

9th parent/carer name

Gender

DOB or approximate age

Relationship to child

Ethnicity

First language

Telephone number

Email address

Address

Add another

Please complete the details below

10th parent/carer name

Gender

DOB or approximate age

Relationship to child

Ethnicity

First language

Telephone number

Email address

Address

Do you have significant safeguarding concerns about this child?

What are you worried about?

What is working well?

Voice of the child(ren) – Please tell us anything the child has said about their life and family in their own words

A day in the life of the child(ren)- Please tell us what you think a day in the life of the child(ren) is like from observations or what you know

What family or friends currently support the family or are important to the family and children

What needs to change and what do you think would help to make this change happen?

On a scale of 1-10 how worried are you about this child/young person?
1 meaning that you are extremely worried and 10 meaning that you have no worries at all

Has there been clear disclosure of physical or sexual abuse?

Has there been an injury that a professional has deemed significant?

Is the child homeless?

Is the referral concerning asylum?

Are there any other agencies working with the family to your knowledge?

Agency 1

Name

Role

Contact details

Agency 2

Name

Role

Contact details

Agency 3

Name

Role

Contact details

Is anyone in the family involved in crime and or anti social behaviour?

Do any of the children not attend school regularly?

Do the family require more or additional support?

Is anyone in the family affected by health issues (including mental health)?

Has anyone in the family been affected by domestic abuse?

Does anyone in the family claim out of work benefits, or are at risk of financial exclusion?

Is the young person at risk of being "not in employment, education or training" (NEET)?