ACTION FOR CHILDREN SERVICE REQUEST
REFERRAL FORM
TOGETHER FOR FAMILIES PHASE 2
FAMILY INTERVENTION PROJECT (FIP)

Please feel free to discuss any potential service requests with the Project:
Action for Children, Helford House, May Court, Truro Business Park, Threemilestone, Truro, TR4 9LD
Tel: 01872 321486
Fax: 01726 341100
Email: [email protected]
Name of young person/ family:
Date of birth:
TF Number :
Disabled Child/Young Person
YES
NO
Type of disability:
Ethnicity:
Gender:
M / F
Parent Details:
Mother: ………………………………. DoB: ..…/.…../…... Parental Responsibilty? YES
NO
Father: ………………………………. DoB: ..…/.…../…...
Siblings:
NO
Parental Responsibilty? YES
Name: ………………………….. DoB: ……/…../….. Name: ………………………….. DoB: ……/…../…..
Name: ………………………….. DoB: ……/…../….. Name: ………………………….. DoB: ……/…../…..
Name: ………………………….. DoB: ……/…../….. Name: ………………………….. DoB: ……/…../…..
Name: ………………………….. DoB: ……/…../….. Name: ………………………….. DoB: ……/…../…..
Family Address:
Telephone No:
The following documents MUST be included with this referral if carried out within the last 6 months –
indicate with a tick which documents you will attaching with this referral.
Early Help Assessment, Plan and Review
CAF, TAC minutes and action plan
Most Recent Assessment
Child Plan
Genogram
Current Plan of Support
Referrer Information
Name
Address
Telephone / Mobile No
1
Email address
Signature
Date
Which statutory, non statutory or
voluntary sector organisation are you
part of? Please detail which
team/department if applicable?
Referral & Assessment (RAS)
ChiN
Children’s Specialist Social Work Service
Child Protection and Children in Care Team
Localities(please state which Locality and role)
TF Advocate
EWO
Police
ASB
Addaction
Other ……………………………………...…………(please specify)
2
TOGETHER FOR FAMILIES (see Together for Families Sheet for details)
TF Number (if known) ………….

Phase Two of the Together for Families programme begins on the 1st April 2015. Families may be
eligible for inclusion onto the programme if they qualify under at least two of the six headline
problem areas listed below. More detailed examples are given on the attached sheets.

Please tick as appropriate and complete the source sections as well
Parents or young people involved in crime or antisocial behaviour
Source of this information: ……………………………………..
Children who have not been attending school regularly
Source of this information: ……………………………………..
Children who need help, ranging from early help to child protection plans
Source of this information: ……………………………………..
Adults out of work or at risk of financial exclusion, or young people at high risk of worklessness
Source of this information: ……………………………………..
Families affected by domestic violence and abuse
Source of this information: ……………………………………..
Parents or children with a drug & alcohol issues or diagnosed health problem
Source of this information: ……………………………………..

Families will be prioritised based on their complexity and likelihood to benefit from whole-family
intensive support and who are positive about engaging with the service.

Referrals to FIP should be made by submitting a fully completed Action for Children referral form.
Partial or missing information will result in return of the form and will delay a decision on the
family’s eligibility

Completed referral forms should be returned to Action for Children at the address or email address
on this form. We aim to process referrals within 2 working days.
3
Please identify what assessments and plans are currently in place and for which member of the
household and attach copies.
Plans in place
Name:
Name:
Name:
Name:
Name:
…………
…………
…………
…………
…………
CAF/TAC
Child Protection Plan
Child Plan (CIC)
Children in Need Plan
Early Help Plan
Statutory Education Order
ASB (e.g. ASBO or ABC)
Other: please specify
Additional Information:e.g. Are you aware of any danger associated with home visits? If yes, please give details. For
example, dangerous dogs, syringes, violent family/visitors, adult family members with restricted
access to the family, or is there anything else we need to know?
4
What additional services or support do you think would benefit this family and help them achieve
their objectives?
What support do you think this family would benefit from?
What is the role you see for FIP?
1.
2.
3.
4.
Consent
Ensure consent is obtained from the family for a Request and for sensitive information to be shared
with professionals in the Early Help Hub. Please note anybody over 13 years, who is deemed
competent, can give their own consent. This may be with or without parental consent.
By ticking this box, you are confirming that the following verbal consent has been given: “I agree to
this Request and to my information being shared with agencies who are part of the Early Help Hub
response”:
Name of person giving consent __________________________________Date ___________
Send this request to the Early Help Hub [email protected]
Please state the service you are requesting in the subject box of your email. This will assist in the
triaging of your request.
Telephone enquiries: 01872 322277 Monday to Thursday 8.45am to 5.15pm
Friday 8.45am to 4.45pm
Or visit the website www.cornwall.gov.uk/earlyhelphub
5