STOP: IF YOU BELIEVE A CHILD IS AT IMMEDIATE RISK OF HARM CALL 999 NOW
Section 1 - About the Child
First Name
Last Name
Address
Post Code
Date of Birth
or Expected
Delivery
Date
Ethnicity
Telephone Number
If Unknown,
please Estimate
the Child's Age
[DD/MM/YYY
Y]
Gender
Status:
Choose an item.
Ethnicity:
Choose an item.
If Other,
Please State
Here:
Any
Disabilities?
Choose an item.
If other,
please
state:
Religion
Choose an item.
If yes, please state
Choose an item.
If yes, please state
which language
(including sign
language)
Choose an item.
GP
Is an
Interpreter
Required?
School
Attended
If you have selected other for
School, please State Here:
Choose an item.
Unique Pupil Number (UPN):
NHS Number:
Section 2 - Details of the family - Father/Mother/other siblings or family members and/or significant others/adults (including perpetrator if
applicable)
First Name
Last Name
DoB/est.
DoB/Age
Ethnicity
Choose an item.
Choose an item.
Choose an item.
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Choose an item.
Does the family need support
with Financial Stability?
Choose
an item.
Gender
Address and
Telephone Number
Choose an
item.
Choose an
item.
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item.
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item.
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item.
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item.
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item.
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item.
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item.
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item.
Does the family needs funding
support for an Early Learning Place
or support relating to employment
help
Choose an
item.
Relations
hip to
Child
Choose an
item.
Choose an
item.
Choose an
item.
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item.
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item.
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item.
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item.
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item.
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item.
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item.
If yes, please provide
the parent/carer NI
number if available:
School and/or GP
Section 3 - About You
First Name
Last Name
Name of Organisation
Job Title
Email Address
Telephone Number
Relationship to the
Child/Your agency's Role
or Service Provided
Contact Address
Section 4 - Details of Professionals involved with the Child or Family (including GP, School, Health, Worker/Family Worker, etc.)
Name
Relationship to
Child
Organisation
Telephone Number
Address
What is their view?
Has an early help
assessment already been
completed?
Choose an item.
If no, please attach
support
plan/professional
summary
If no, what has been done
to support the family
already?
Have you discussed this
already e.g. with a MASH
Officer or Early Help?
If yes, please name
the lead professional
If yes, please
attach Early
Help
Assessment
If yes, who did you
speak to?
Choose an item.
Is this a child with a complex disability?
Choose an item.
Section 5 - Reason for Concern (if your concern is about a vulnerable adult/carer we still need you to complete this section) or any other factors to
take into consideration
Why are you concerned
about the child?
What has prompted
you to make this
referral?
Was anybody else
present?
When did this happen?
DD/MM/YYYY/Time
What has the child said
or experienced?
Is there an indication of
physical harm to the
child?
Where is the child & who
are they with right now?
When did you last see the
child/family?
Choose an
item.
If yes, please
describe
Is there suspected or a history of…
Sexual Abuse?
Alcohol or Substance
abuse?
Mental ill health?
Emotional abuse or self
harm?
Choose an
item.
Choose an
item.
Choose an
item.
Choose an
item.
Please Describe in Further Detail…
Please Describe in Further Detail…
Please Describe in Further Detail…
Please Describe in Further Detail…
Neglect?
Domestic Abuse?
Child Sexual
Exploitation?
Trafficking?
Female Genital
Mutilation (FGM)?
Forced Marriage?
Honour based
violence?
Extremism?
Choose an
item.
Choose an
item.
Choose an
item.
Choose an
item.
Please Describe in Further Detail…
Please Describe in Further Detail…
Please Describe in Further Detail…
Please Describe in Further Detail…
Choose an
item.
Please Describe in Further Detail…
Choose an
item.
Choose an
item.
Choose an
item.
Is the child missing
from home or school?
Choose an
item.
Does the child of the
family have a legal right
to be living in the UK?
Choose an
item.
Please Describe in Further Detail…
Please Describe in Further Detail…
Please Describe in Further Detail…
Please Describe in Further Detail…
Please
Describe:
What action have
you/your agency taken
to address this specific
concern?
Please confirm how
long you have been
involved; including any
historical concerns and
actions taken
What actions would
you like to see from
Croydon Council?
Using your professional
knowledge, please rate
the level of risk
involved:
If known,
Severity:
Choos
e an
item.
If known,
frequency:
Choose an
item.
If known,
duration:
Choose an
item.
If known,
overall Stage:
(Croydon
Pathways)
Choose an item.
The Child/s Voice
I have spoken to the
child about my concern
and they are aware of
this referral
Choose an
item.
The reason I have not
spoken to the child
about my concern
is….
If you have spoken to
the Child, what is their
viewpoint on the
situation?
Section 6 - Parent or Carer Consent
Getting parental consent has a significant impact on our ability to respond, particularly if we would like to be able to offer the family Early Help;
- As a referrer working with the child or family, it is your responsibility to speak with the Parent/s or Carer/s about your concerns.
- Specifically we need you to seek consent from parents or carers when making a referral (where this does not put the child at risk of harm).
- If you are unable to obtain consent you must explain why this is not possible.
What level of consent have you obtained? Choose one statement which best matches your situation
a) I have spoken to the child's parents or carers to discuss my concerns and they are aware that I am making a
referral but have not given their consent
Choose an item.
b) I have spoken to the child's parents or carers and they have given me consent to make this referral
Choose an item.
c) I have not spoken to the child's parent or carers and I have provided an explanation below as to why this has not
been possible
Choose an item.
The reason I have not spoken to the
child's parent or carers/ have not gained
consent is:
END of Referral form
Our promise:
Croydon Multi-agency Safeguarding Hub, promise to use the information you provide to respond appropriately and proportionately to your
concerns, and identify children at risk of significant harm, (including those with complex needs or additional needs). If the child or family's needs
do not meet statutory social care thresholds, we will contact you to discuss the Early Help offer.
In return you agree to:
- Provide as much information about the family or situation as possible, this will enable us to respond in a shorter space of time
- Where possible (and if appropriate), discuss your concerns with the child/ family and gain their consent - if the referral does
not meet the statutory social care threshold and would benefit from the Early Help Services, consent is a compulsory part of the
offer.
- Remember that the more information you submit, the less likely we are to ask for additional details later (which takes time)
How to submit this form:
Please attempt to complete ALL sections of this form (failure to do so may lead to unnecessary delays), save it securely, and email it to MASH:
- If you have secure e-mail, the address is [email protected]
- If you do not have a secure email, please complete and send to [email protected]
Please only send your completed form to one email box.
You can speak to a MASH social worker on 0208 726 6400. Consultations can be held over the phone but must be followed by a referral form as
soon as possible and within 24 hours.
CONSENT GUIDANCE AND PRIVACY
For practitioners:
Croydon collects personal and sensitive information about the families it supports. The Early Help offer operates a consent based model to collect
this information so families can be informed about how their data is used. All data is processed and stored in accordance with the Data Protection
Act 1998. For more information about Data Protection and Fair Processing please visit: [insert www. link to practitioner space privacy notice?)
Consent may be given or withdrawn at any time, if consent is withdrawn you must inform the Council as soon as possible. All Croydon & Partner
services should re-visit consent with the family’s they support on a periodic basis.
The guidance below should be discussed with the family before they are asked to give consent.
Consent guidance (for families):
We need to collect information about you/ your family as part of this referral so we can better understand what help you may need. We will
cross reference your information against other internal Council data systems to ensure you receive any support to which you may be entitled.
In order to provide the most appropriate support to you / your family, it may be necessary for us to share some of this information with other
Council teams and Partner agencies. All information supplied is processed and stored in accordance with the Data Protection Act 1998, and we
will only ever share the minimum information needed to enable those teams and or agencies to provide appropriate support.
In certain situations, the Council may be required by law to share your information with other Council departments or Partner agencies to
prevent harm to you or members of your family. If there are any concerns about the safety and / or wellbeing of a child / young person / family,
local safeguarding procedures will be followed.
Information that Croydon (and Partners) collect about families will be used to:
- Identify families who might be eligible or entitled to support from the Council;
- Carry out other statutory and specific functions related to Child Protection and Safeguarding;
- Derive statistics for local research purposes - to inform decisions about service provision and assess performance of services
(quality assurance and service improvement). Any statistical data is reported in such a way that individual families cannot be
identified
– your information is anonymised
Where the Council identifies a family as being eligible to receive support under national Troubled Families Programme, we are required to share
personal information (name and date of birth) for research purposes with the Department for Communities and Local Government (DCLG). This
will not affect a family’s benefits, services or any treatments. Information will be anonymous and handled in accordance with the law.
Information is used to help improve services.