FORM-PKS Family Support Referral - Please complete all sections of this form

Please complete all sections of this form

Please confirm this is the form you require PKS FAMILY SUPPORT REFERRAL or close this tab to return to the form selection screen.

Please provide details of all children /young people being referred

Child /young person 1: Local Authority ID Number

Child /young person 1: Gender/Identifies as (pronoun)

Child /young person 1: Forename

Child /young person 1: Ethnicity

Child /young person 1: Surname

Child /young person 1: Religion

Child /young person 1: Date of birth

Child /young person 1: Language

2nd Child /Young person

Child /young person 2: Local Authority ID Number

Child /young person 2: Gender/Identifies as (pronoun)

Child /young person 2: Forename

Child /young person 2: Ethnicity

Child /young person 2: Surname

Child /young person 2: Religion

Child /young person 2: Date of birth

Child /young person 2: Language

3rd Child /Young person

Child /young person 3: Local Authority ID Number

Child /young person 3: Gender/Identifies as (pronoun)

Child /young person 3: Forename

Child /young person 3: Ethnicity

Child /young person 3: Surname

Child /young person 3: Religion

Child /young person 3: Date of birth

Child /young person 3: Language

4th Child /Young person

Child /young person 4: Local Authority ID Number

Child /young person 4: Gender/Identifies as (pronoun)

Child /young person 4: Forename

Child /young person 4: Ethnicity

Child /young person 4: Surname

Child /young person 4: Religion

Child /young person 4: Date of birth

Child /young person 4: Language

Home Address Including Postcode

Full home address and postcode

Parents /Carers details

Parents /Carers Relationship

Parents /Carers Gender/Identifies as (pronoun)

Parents /Carers Name

Parents /Carers Ethnicity

Parents /Carers Phone number

Parents /Carers Language

2nd Parents /Carers details

2nd Parents /Carers: Relationship

2nd Parents /Carers: Gender/Identifies as (pronoun)

2nd Parents /Carers: Name

2nd Parents /Carers: Ethnicity

2nd Parents /Carers: Phone number

2nd Parents /Carers: Language

3rd Parents /Carers details

3rd Parents /Carers: Relationship

3rd Parents /Carers: Gender/Identifies as (pronoun)

3rd Parents /Carers: Name

3rd Parents /Carers: Ethnicity

3rd Parents /Carers: Phone number

3rd Parents /Carers: Language

4th Parents /Carers details

4th Parents /Carers: Relationship

4th Parents /Carers: Gender/Identifies as (pronoun)

4th Parents /Carers: Name

4th Parents /Carers: Ethnicity

4th Parents /Carers: Phone number

4th Parents /Carers: Language

If looked after or residing at a temporary placement, Please provide the full address

Temporary Placement Full address

Is this address confidential?

Confidential address YES / NO

Foster/temporary Carer Details

Foster/temporary Carer Details Relationship

Foster/temporary Carer Details Phone number

Foster/temporary Carer Details Name

Foster/temporary Carer Details Language

2nd Foster/temporary Carer Details

2nd Foster/temporary Carer Details: Relationship

2nd Foster/temporary Carer Details: Phone number

2nd Foster/temporary Carer Details: Name

2nd Foster/temporary Carer Details: Language

3rd Foster/temporary Carer Details

3rd Foster/temporary Carer Details: Relationship

3rd Foster/temporary Carer Details: Phone number

3rd Foster/temporary Carer Details: Name

3rd Foster/temporary Carer Details: Language

Communication

Any Special Communication Needs? If yes please provide details

Registered/Statutory Status. Please give details of name of child/young person, dates, category(if known)

Any child in the family currently on a Child in Need Plan?

Any child in family is or has been on a Child Protection Plan?

Any child or other family member is/has been looked after by a local authority?

Any child in the family has a disability?

Any current criminal proceedings?

Referral Details

Name of Referrer*

Role of Referrer

Contact Number of Referrer*

Email of Referrer*

Name of Authorising Manager

History of Case and Current Situation/Reason for Support Being Required

History and requirement.

Days/dates visits are required

Support Details **Please note, our minimum charge is 1 hour

Days/dates visits are required

Time visits are required (if flexible please provide guideline – eg, anytime between 7am-6pm)

Length of visit/s required**

Announced or Unannounced?

Are parents/carers aware of this referral?

Frequency of visits (please specify, weekly, monthly, one off etc)

Service Requirement

Proposed service start date

Proposed service end/review date

Work to be undertaken. Please give details of outcomes that need to be achieved

Please indicate the frequency that reports are required (after each visit, weekly etc) Please be mindful of the number of visits per week – For example, if visits are being undertaken 7days per week, one weekly report may not be a sufficient amount in order to provide a detailed account of each visit.

Risk Assessment – Child. Please provide details e.g. whether this is current or historical. If YES, how would you like this to be managed by the worker?

Has the young person/child(ren) displayed any sexualised/challenging behaviour?

Has the young person/child(ren) shown aggression towards other children or to adults?

Are there any other risks that may be posed by the young person/child(ren) that the worker need to be aware of?

Risk Assessment – Adult/s. Please provide details e.g. whether this is current or historical. If YES, how would you like this to be managed by the worker?

Does any adult residing in the home have issues of alcohol, solvent, or other substance misuse?

Has any adult residing in the home ever displayed sexualised behaviour towards children or adults?

Has any adult residing in the home ever displayed physical threats or violence towards a professional?

Has any adult residing in the home ever displayed verbal or racist abuse towards a professional?

Is any adult residing in the home engaging in, or have a history of, criminal activity?

Are there any other risks that may be posed by any adult residing in the home that the worker need to be aware of?

Please provide details of where invoices for this service should be sent (Please note, referral will not be accepted if this section is not completed)

Name of person to receive Invoices*

Role of person to receive Invoices*

Department of person to receive Invoices*

Email of person to receive Invoices*

Telephone number of person to receive Invoices*

Authorisation

Authorising Manager*

Date referral was authorised*