Multi Agency Referral Form V8 - Rhondda Cynon Taf

Multi Agency Referral FormChild in Need or Child ProtectionThis form should be completed for all referrals to Children’s Services. Immediate concerns for a child’s safety or well being must bereferred without delay, by telephone, to Children’s Services. The form should then be completed within 48 hours of making anytelephone referral. It should be completed as fully as possible, indicating when information required in a specific section is notknown. Referral forms can be submitted to Children’s Services electronically, by fax or by post (contact details can be found on page6), subject to the referrer’s own agency policy. Additional documents may be attached to the completed form, for example agencyassessments; consent to share this information should be addressed by the referrer as appropriate.Reason for referral, tick box (Referrer’s view)Child in Need Child ProtectionDetails:CHILD(REN)/YOUNG PERSON (INCLUDING UNBORN BABY)1234Child/Young PersonFamily NameFirst Name Gender D.O.B /E.D.DSubject ofReferralAddressCode *School / NurseryPARENTS/CARERS – PLEASE INDICATE WHO HAS PARENTAL RESPONSIBILITY (PR) FOR THE CHILD / YOUNG PERSON1a2a3a4aFamily Name First Name D.O.B Relationship to child ParentalResponsibilityYES / NOAddress Codes *Contact Number1Approved by Rhondda Cynon Taf Local Safeguarding Children Board 26.02.10. Implemented 01.09.10

Child/YoungPerson orAdult asnumbered inprevioussectionAlso Known AsEthnicCode *Religion First Language InterpreterRequiredSignificant others not living at home address:Name D.O.B Relationship Address Code*Address Codes*Addresses1234Are there any safety concerns for professionals visiting any of these addresses or people? Yes No Not KnownIf ticked yes please give brief details2Approved by Rhondda Cynon Taf Local Safeguarding Children Board 26.02.10. Implemented 01.09.10

2. Parent capacity. This includes basic care, ensuring safety, emotional warmth, stimulation, guidance and boundaries, stabilityand any issues likely to effect parenting capacity. Please include strengths and current needs.Does the Parent / Carer have a Disability / Special Needs? Yes No N/KIf YES please attached detailed information.Immigration status if relevant3. Family and social environment factors. This includes community resources, family’s social integration, income, employment,housing, wider family history and functioning. Please include strengths and current needs4Approved by Rhondda Cynon Taf Local Safeguarding Children Board 26.02.10. Implemented 01.09.10

Is the Parent/Carer aware of the referral? Yes NoHas consent been obtained for the referral? Yes NoWritten VerbalIs the Child/Young Person aware of the referral? Yes NoHas consent been obtained for the referral? Yes NoDate Consent Obtained:Written Verbal (If Written consent obtained, please attach copy)If no, please give reason:Referrers Name:Date, time and name of person who took telephone referral:Designation/Agency:Contact DetailsSigned: Date:Name and Contact Details for person to receive Referral Feedback Form:5Approved by Rhondda Cynon Taf Local Safeguarding Children Board 26.02.10. Implemented 01.09.10

Contact DetailsRhondda Children’s Services, Berw Road, Tonypandy,Rhondda Cynon Taf, CF40 2HHTel: 01443 431513Fax: 01443 424542Email: csiatrhondda@rctcbc.gov.ukCynon Children’s Services, Ty Caradog, Gaswork Road,Aberaman, Aberdare, Rhondda Cynon Taf, CF44 8RSTel: 01685 888800Fax: 01685 888888Email: csiatcynon@rctcbc.gov.ukTaff Ely Children’s Services, Courthouse Street, Pontypridd,Rhondda Cynon Taf, CF37 1LJTel: 01443 486731Fax: 01443 484115Email: csiattafely@rctcbc.gov.ukDisabled Children’s Team, Units 13 & 14 Centre Court, TreforestIndustrial Estate, Treforest, Rhondda Cynon Taf CF37 5YRTel: 01443 665455Fax: 01443 665465Email: not available at presentEthnic Codes*:A: White British G: Any other mixed N: Black/Black British AfricanB: White Irish H: Asian/Asian British Indian P: Any other BlackC: Any other white J: Asian/Asian British Pakistani R: ChineseD: Mixed White/Black Caribbean K: Asian/Asian British Bangladeshi S: DeclinedE: Mixed White/Black African L: Any other Asian Z: Not GivenF: Mixed White/Asian M: Black/Black British Caribbean6Approved by Rhondda Cynon Taf Local Safeguarding Children Board 26.02.10. Implemented 01.09.10

Referral Feedback SheetReferrer’s Name:Designation/Agency:Address:Date of Referral:(Feedback to be provided within 10 working days)Name of Child/FamilyAddress:Thank you for your referral (please tick as appropriate):1. No Further Action Needed – Case Closed2. Signposted to another agency – Name of Agency:3. Undertake an Initial Assessment4. Undertake a Child Protection (Section 47) EnquiryComments: (Brief reason for decision and appropriateness of referral)Contact details of allocated Social Worker (include email):Signed:Print Name:Date:7Approved by Rhondda Cynon Taf Local Safeguarding Children Board 26.02.10. Implemented01.09.10