Early Help Referral Form
Estart registration number - to be
completed by the Children’s Centre
How to complete this form
IF YOU ARE A GP OR HEALTH VISITOR OR OTHER PROFESSIONAL and want to refer a parent for
additional help then complete pages 1 and 2, ask the parent to sign page 3 to say they give consent to
sharing their information with the Children’s Centre and with Croydon Council and send to your local FEP.
Please give as much information as possible.
PARENT(S) / MAIN CARER(s) DETAILS – this section MUST be completed
Main parent/carer
Other parent/carer
Full Name
Address inc postcode)
Tel number
Email address
Home language
Ethnicity
Male/female
Date of birth
Male/female
Date of birth
Please detail any additional or communication needs (parent).
DETAILS OF CHILDREN – this section MUST be completed for at least 1 child aged under 5
First child
Second child
Third child
Fourth child
Name
Date of birth /
estimated due date
Male / Female
Additional needs
Relationship to
main carer
Relationship to other
carer (if applicable)
GP name, address and tel. no.
Health clinic the family is registered with and the name and tel. no. of health visitor (if known)
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Early Help Referral Form (continued)
REFERRAL DETAILS AND CONSENT – this section MUST be completed if not a self referral
Referral
Referrer name
agency and
Referrer contact number
address
Date
Referrer email / fax no.
Consent
Yes
No
Attached
Yes
No
What has led you to making this referral? (please complete with parent/carer and tick all that apply)
Child’s behaviour
Disability (child or
parent/carer)
Parenting / bonding
Child development
Domestic violence
PND/AND/mental health
Childcare*
Money / finance
Drug, alcohol or substance misuse
Child’s health (weaning,
weight)
Other (please state)
* if the referral is for funding for an Early Learning Place for a two year old please provide the parent/carer NI
number
Further information: please give us a little bit more information about the reasons for the referral along with
other information that the family has given consent to share for example a copy or summary of any
assessment you have already done or case notes you have made.
Where to send this form


Parents - hand this form with the signed consent statement to your local Children’s Centre.
External referrers - return this form with the signed consent statement to the local FEP
Coordinator or CRISS*
By post or by hand
By password
protected email
By secure fax
*If you are not sure which FEP to send the form to please send to CRISS
By email
[email protected] By secure fax
020 8633 9436
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Consent statement for information storage and information sharing
The information in this form will be treated as confidential and stored securely / recorded on a secure
database.
In order to provide the most appropriate support to you / your family it may be necessary to share this
information with other organisations that may be able to provide the services you need and for quality
assurance / inspection purposes. However, only the minimum information that is needed will be shared.
If there are any concerns about the safety and / or wellbeing of a child / young person / family, local
safeguarding procedures will be followed.
Confirmation of Consent
1. I understand the information recorded on this form and agree that it is accurate.
YES
NO
2. I have read and understand the consent statement and agree to the secure storage and
sharing of this information.
YES
NO
If required
3. I do not want information shared with: (please say which information you not want to share and
which agencies/organisations you do not wish your information to be shared with)
Parent / Carer
Name:
Signature:
Date:
Signature:
Date:
Referrer
Name:
Please return this form with the Early Help Referral Form to your local Children’s Centre, FEP
Coordinator or to the CRISS team.
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