Targeted Early Help and Children's Social Care referral form

If you are concerned that a child is at immediate risk, call the police on 999

If you are worried about risk of significant harm to a child, it is essential that you share your concerns by telephone and you will need to follow this up by completing the online referral form within 24 hours.

Mandatory fields are marked with an asterisk (*). These fields must be completed before the form can be submitted.

Is this a referral for?

Targeted Early Help Service

Children's Social Care services (you are worried about the safety of a child)

Please state who you had a consultation with and what actions were agreed.

Referrer's details

Name*

Job title

Relationship to the child*

Please specify

Organisation

Contact tel no

Email (If you are a professional, please enter your organisational email)*

Secondary contact tel no (option to give an alternative number in case the referrer is unavailable)

Address including postcode (If you are a professional referring the child, please provide your organisation's address)

Please summarise your involvement with this child/family including support offered and engagement with your service.*

Educational setting/nursery/school details

If you have already provided details of the child's educational setting in the Referrer's Details section, you do not need to complete this section.

Is the child at an educational setting, nursery or school?

Yes

Other

Other educational setting

Educational setting/nursery/school name, address & telephone number (Please include any dual registration/alternative provision arrangements)

Name of person who has given consent

Relationship to child

Date of consent

Concerns outside the home/extra-familial harm: complete for young people aged 10+

We know young adolescents can be at risk of harm from factors outside of the home For example, from their peer group/associates, online usage or within the community. Are you concerned about any of the following:

1) The child’s friends/peer group/gang association

Yes

2) Risk from online use

Yes

If yes, give details of the nature of the harm and name the social media platform if known

3) Risk in the community – is the child frequenting a location/place that increases vulnerability?

Yes

If yes, give details of where the child frequents that raises concern

Reason/s for referral

Reason for referral*

Please succinctly summarise facts and your analysis of risk

What is the impact on the child/young person?*

What is their lived experience?
How is this affecting the child’s health, development and well-being?
What are you worried will happen if nothing changes?

What else do you know about this child/family (including any historical concerns)?

What do you want to happen to address the concerns you have raised?*

If you have any additional relevant information, please upload here:

Unlimited number of files can be uploaded to this field.
5 MB limit.
Allowed types: gif, jpg, jpeg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, mp4, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.

Child's views about the reason for referral*

What do they say they are worried about?
How does this relate to the reason for referral?
If child's views are not sought, please explain why

Parents’ views about the reason for referral*

What do they say they are worried about?
How does this relate to the reason for referral?
If parents' views are not sought, please explain why

Parent 1/carer 1 details

First name*

Last name*

Date of birth

Does this parent/carer live at the same address as the child?*

Yes

Not known

Parent/carer's current address

Parent/carer's contact number*

Parent/carer's secondary number

Relationship to the child

Interpreter or signer/communicator required?

Yes

Please specify which language is required

Parent 2/carer 2 details

First name

Last name

Date of birth

Does this parent/carer live at the same address as the child?

Yes

Not known

Parent/carer's current address

Parent/carer's contact number

Parent/carer's secondary number

Relationship to the child

Interpreter or signer/communicator required?

Yes

Please specify which language is required

What are the strengths/support systems within the family?

Other household members and significant relationships outside the household

Are there any other household members or significant relationships?*

Yes

Not known

Please provide names and relationship to the child

Any other professionals/agencies involved with this family

If known, please provide names of other organisations and agencies involved with the family and how they have been involved

If you have any other supporting documents to submit, please upload here

What happens next

You will receive an automatically generated response immediately after this form has been submitted.

A decision will be made within 72 hours of receipt of a fully completed form (24 hours if there are urgent safeguarding concerns) and you will be notified accordingly.

If you do not hear back from us regarding the outcome and/or progress of your referral, please contact the MASH Team on 0208 227 3811 (Monday to Friday between 9am and 4:45pm) or the Targeted Early Help Service on 020 8227 5600 depending on who you made your referral to.

By clicking the submit button, you agree to the information you provide on this form being processed in line with our data protection policy.

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You will get a copy of this referral form. If you want add another email where a copy should be sent, please provide it here