Referral Form

This form is to be used when making a referral to Children's Social Work Services, Early Help Support or Youth Offending Service.

Important

Before making a request for support through this referral have you:

Discussed your concerns with the child and family (unless to do would place the child at risk of harm) and gained their consent? (Read more about information sharing).
Considered the threshold guidance and thought about whether you are making a referral to the right service for the right reasons?

Remember: In making this referral you are not passing the case on, but are asking us to join you in your work.

Please do not use the following special characters in any text: { } [ ] < > *

Please do not include any profanities and/or swearing in your form as this may result in it being blocked.

* Denotes a mandatory field.

Consent and Information Sharing

Have you discussed this referral with the child or young person? YesNo

Have you discussed this referral with the person with parental responsibility and gained their consent? YesNo

If no to either of the above, why not?

Are you confident that the family understand the next steps? YesNo

Have you explained that the information you provide may be shared with agencies (such as children's services, the police, education, housing and health services) to ensure the child and family get the right service? YesNo

Comments of child/young person regarding this referral (if applicable):

Comments of family members (if applicable):

Referrer Details

*Date:

*Time:

*Name of Worker completing referral:

*Job Title:

*Secure Email Address: A confirmation email will be sent to this email address.

*Agency:

*Telephone Number:

It is expected that a referrer is available to clarify and discuss the information contained in this referral for 72 hours. Please ensure a colleague is aware of this information in your absence.

Children in household

*Address:

	Child's Name	DOB/EDD
No details exist.

Who else lives with the child(ren)?

	Name	Relationship	DOB
No details exist.

Other people who don't live with the child(ren) but are significant

	Name	Relationship	DOB
No details exist.

Professionals involved with the child(ren) and family

	Type	Name	Role
No details exist.

What are you worried about (include all of your concerns about the child/family)?

What is the impact of this for the child currently and identify the risks if the situation doesn’t change?

What is working well for this child?

Are there any other plans in place (e.g. Early Help Assessment, Education Health Care Plan, SOLAR Assessment, YOT Asset Plus)? YesNo

Please attach details of any other plans in the uploads section at the bottom of this form.

Everyone is different - is there anything else we need to consider?

Outline individual factors e.g. culture/lifestyle, learning styles, maturity, finances, time keeping, communication needs, education commitments, caring responsibilities, learning and physical disabilities etc.

Referral Type

Children's Social Work Services (MASH) work with those children who have been identified as requiring statutory help and protection.

Early Help Support supports the delivery of early help across Solihull.

The Youth Offending Services works with children who have offended or are at risk of offending behaviour and support children/young people displaying sexually harmful behaviours.

For more information see the threshold guidance.

If you wish to discuss the referral or need advice please contact:

The MASH Team 0121 788 4300
Early Help Support 0121 788 4300 option 2
The Youth Offending Service 0121 709 7000
Emergency Duty Team (EDT - out of hours) 0121 605 6060

*Which team is this referral for?:

Submit Form

Please tick the confirmation box and click on the 'Submit Form' button below when you have completed this referral form with all the information and details available to you.

Following this, you will shortly receive an e-mail at the secure email address entered above in the 'Referrer Details' section, confirming this referral form has been sent securely.

If you do not receive this automated confirmation e-mail the referral form may not have been completed and therefore not sent. Please ensure you have submitted the form before exiting as it will not save the information.

* I confirm that this referral form is now completed and ready to be sent.

Upload documents

To attach a document to this form, drag and drop it to the area below, or click the 'Upload file' button. To remove the attachment, click the icon.

A maximum of 5 files can be uploaded, of the following type: jpeg, jpg, gif, png, bmp, doc, docx, pdf, txt

Children's Services

Inter-Agency Referral Form