Date of referral (dd/mm/yyyy):

Single Agency without CAF (complete all sections):

Select... Single Agency without CAF Single Agency with CAF

Children’s Social Care without CAF (complete all sections)

Children’s Social Care with CAF (complete sections 1, 2, 3 and 7)

Section 1: Referrer’s Details

Referrer:

Agency:

Role:

Telephone:

Email:

Line Manager:

Section 2: Child / Young Persons Details

Family name:

First name:

AKA/Previous names:

Gender:

Select... Male Female Unborn Unknown

Date of birth or EDD:

Address:

Postcode:

Telephone:

Ethnicity:

Child's first language:

Parent/Carer's first language:

Religion:

Immigration status:

Select... Not Known Asylum Seeker British Citizen Discretionary Leave to Remain in the UK to 18 (DLR) DLR to 18th Birthday, extension applied for Exceptional Leave to remian in the UK (ELR) Exhausted Asylum Appeals Humanitarian Protection applied for under ECHR Indefinate Leave to Remain in the UK (ILR) Refugee Status Refused Asylum Appeal applied for Returned home or Deported Unaccompanied Asylum Seeking Child

Does the child have an identified Special Educational Need?:

Select... Yes No

If yes, please indicate at what level:

Please indicate what the SEN Primary Need of the child is:

Select... Specific Learning Difficulty (SpLD) Severe Learning Difficulty (SLD) Behaviour, Emotional & Social Difficulty (BESD) Autistic Spectrum Disorder (ASD) Multi-Sensory Impairment (MSI) Moderate Learning Difficulty (MLD) Profound & Multiple Learning Difficulty (PMLD) Speech, Language & Communication Needs (SLCN) Visual Impairment (VI) Physical Disability (PD)

Do you consider the child to have a disability, as defined by the Disability Discrimination Act (DDA)?:

Select... Yes No

If yes, please provide details:

Details of any special requirements (for child and/or parent/carer):

Section 3: Reason for referral

Reason for referral:

What involvement has the referring agency had prior to referral?:

What outcome(s) are you seeking for the child/family?:

If a CAF has not been completed, please detail why:

Section 4: Details of parents/carers and family

Family Name:

First Name(s):

Gender:

Select... Male Female Unknown

Relationship to unborn baby, child or young person:

Address:

Postcode:

Telephone:

Parental Responsibility?:

Select... Yes No

Please list below the names and details of all children and adults who are currently residing with the child or young person:

Family Name:

First name:

Date of birth / Age:

Relationship to the child/young person:

Section 5: Services working with this infant, child or young person

Service

GP name:

GP address:

GP Contact Number:

School, Nursery, Early Years or education provision:

School, Nursery, Early Years or education provision address:

School, Nursery, Early Years or education provision contact number:

Health Visitor name:

Health Visitor address:

Health Visitor contact number:

Other contact:

Other contact address:

Other contact number:

Section 6: Supporting information for referral

Please consider the three domains listed below, thinking about the areas covered by these domains in the CAF.

1: Development of unborn baby, infant, child or young person:

2: Parents and Carers abilities/influence:

3: Family and environmental factors:

Other factors not covered by the above:

Section 7: Consent

Person giving consent:

Select... Parent/Carer Young Person No consent required

Consent is not required if the referral meets the Threshold for Safeguarding / Prevention and Detection of crimes. If no consent given, please justify why the referral is being made without consent:

Comments of parent/carer and/or the child or young person:

Do you have written consent?:

Select... Yes No

Date (dd/mm/yyyy):