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Lewisham Children & Family Centre
Professionals Referral Form
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SECTION A: REQUIRED INFORMATION ABOUT THE REFERRER and the FAMILY BEING REFERRED
REFERRER’S DETAILS
Date of Referral
*
DD slash MM slash YYYY
Name of Professional making the referral
*
Organisation / Team
*
Telephone Number
*
Email
*
PARENT/CARER
FIRST NAME
SURNAME
M/F
RELATION TO CHILD
D.O.B
ETHNICITY
RELIGION
NHS NUMBER
CHILD (Please list all children in the family)
FIRST NAME
SURNAME
M/F
D.O.B
SCHOOL
CPP/CIN
ETHNICITY
RELIGION
NHS NUMBER
Use the plus button at the end of the line to add more children
Address and Postcode of Family
*
Phone Number
*
Main Carer's Email Address
ANY OTHER SIGNIFICANT MEMBERS OF THE HOUSEHOLD OR FAMILY
NAME
RELATIONSHIP TO FAMILY
ADDRESS and POSTCODE
TEL / MOBILE
E-MAIL
SAFE TO CONTACT?
SAFE CONTACT NOTES
PROFESSIONALS WORKING WITH FAMILY
Are Children’s Social Care involved with this client/family?
Please indicate the nature of their involvement in the field below.
Name and contact details of Social Worker
Name
Tel
E-Mail
LCS Number
Are Early Help involved with this client / family?
*
Yes
No
Unknown
Is there a SOS / EHA / TAF plan for this family?
*
Yes
No
Unknown
Name and contact details of Family Support Worker:
Name
Tel
E-Mail
Are the Police involved with this client / family?
*
Yes
No
Unknown
Name and contact details of Police Officer involved
Name
Tel
E-Mail
Is there an IDVA or IGVA involved with this client / family?
*
Yes
No
Unknown
Name and contact details of IDVA or IGVA:
Name
Tel
E-Mail
Please list anyone else involved in supporting the client / family.
SECTION B: REFERRAL DETAILS
PRESENTING REASON FOR REFERRAL
*
What has led to this referral? What are you worried about and why? (Please include family history, context and impact on child of current circumstances)
WHY ARE YOU REFERRING TO US
*
Please explain what kind of support you feel we can offer that would benefit the family and how you will know when things have changed. Note: if domestic abuse features as a presenting issue, please ensure that you complete SECTION C.
Do any of the family members have a special need, physical disability or mental health needs?
*
Yes
No
Unknown
If Yes, please give details below
Have there have been any issues relating to violence/abuse within the family?
*
Yes
No
If yes, then please complete SECTION C on the proceeding page.
Please click Next to proceed
SECTION C: REFERRALS FOR THE COMMUNITY GROUPS PROGRAMME, THE FREEDOM PROGRAMME AND/OR WHERE DOMESTIC ABUSE HAS BEEN EXPERIENCED
The Community Groups Programme
The Freedom Programme
The Community Groups Programme is a twelve-week therapeutic programme for women and children who have experienced domestic abuse. It seeks to enable the recovery process and aims to:
• Validate the children’s experiences.
• Reduce the self-blame that is commonly associated with children experiencing abuse.
• Develop a child-appropriate safety plan.
• Manage appropriate and inappropriate expressions of emotion.
• Enhance the mother-child relationship.
• Enable both the mother and child to heal together.
The Freedom Programme is for women who are experiencing or surviving domestic abuse. It usually runs for eleven or twelve weeks (but this may vary depending on your locality) and aims to:
• Provide women who are experiencing or surviving domestic abuse with a safe, supportive and friendly environment.
• Allow women to recognise the tactics and behaviours of ‘the dominator’ – that is, the tactics that typify a perpetrator of domestic abuse.
• Give women the opportunity to build connections with other women.
ABOUT THE ABUSE
Risk level - today
Low
Medium
High
Professional Judgement
DASH RIC Score
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
MARAC
Yes
No
Unknown
If yes, please indicate outcomes from MARAC
Has any of the following been experienced?
Physical Abuse
Stalking / Harassment
Financial Abuse
Emotional Abuse
Honour based violence
Coercive control
Sexual Abuse
Psychological Abuse
Forced marriage
Are they still in a relationship with the perpetrator of domestic abuse?
Yes
No
Unknown
How long were they in a relationship with the abusive person?
< 6 Months
6m - 1 Year
1-2 Years
2-3 Years
3-4 Years
5-6 Years
7-8 Years
8-9 Years
9-10 Years
10-15 Years
15+ Years
When did the relationship end?
Does the perpetrator/alleged perpetrator still reside in the family home?
Yes
No
Unknown
If no longer in the relationship with the alleged perpetrator, is the client currently in a new relationship?
Yes
No
Unknown
Please detail how the child/children have been impacted by the abuse:
Please click Next to proceed
INFORMATION ABOUT THE PERPETRATOR/ALLEGED PERPETRATOR (IF KNOWN)
Name:
Relationship to Client:
Address:
Date of Birth:
MM slash DD slash YYYY
Does the perpetrator / alleged perpetrator have contact with the children?
Yes
No
Unknown
Is there a non-molestation order in place?
Yes
No
Unknown
Is there a prohibitive steps order in place?
Yes
No
Unknown
Is the perpetrator/alleged perpetrator known to probation services?
Yes
No
Unknown
Are there any licence/bail conditions or current proceedings taking place in relation to the Domestic Abuse?
Yes
No
Unknown
If yes, please provide details:
If there is more than one alleged perpetrator, please provide additional details below:
SECTION D: FAIR PROCESSING AND CONSENT FORM
Here at Lewisham Children and Family Centres we take your privacy very seriously with your consent we will process, retain and store your personal data on behalf of the London Borough of Lewisham in line with the General Data Protection Regulation (GDPR) (EU) 2016/679. Your personal data and contact details will not be shared with any other third party or organisation but may be shared with other Children and Family Centres, and other partnership organisations. You have the following rights regarding your personal data: • The right to withdraw consent at any time • The right to request your personal data is deleted • The right to access to your personal data For more information regarding the use of your personal data please see www.lewishamcfc.org.uk or make a request to: Lewisham.Secure@eyalliance.org.uk or Early Years Alliance, Camelot Centre, 50 Meliot Road, London, SE6 1RY and a copy of the policy will be sent to you.
*
I understand that by providing my consent I am confirming I understand how and why my personal data is used and give permission for Lewisham Children and Family Centres to store and update my personal details.
*
I am a parent/legal guardian of a child/children under the age 16 and give consent for Lewisham and Children Family Centres to store and use my child/children’s personal data for the purposes of the service.
*
I give permission to Lewisham Children and Family Centres and any relevant partner organisation to contact me regarding services available and my access to them by:
Email
*
Yes
No
Post
*
Yes
No
Telephone (including text messages)
*
Yes
No
PLEASE CONFIRM THAT THE PARENT HAS GIVEN VERBAL CONSENT FOR THIS REFERRAL. NOTE: A REFERRAL WILL NOT BE ACCEPTED WITHOUT EITHER WRITTEN OR VERBAL PARENTAL CONSENT
*
VERBAL CONSENT HAS BEEN GIVEN
Date Consent Given:
*
MM slash DD slash YYYY
REFERRER’S NAME:
*
Please type name
Date:
*
MM slash DD slash YYYY
Phone
This field is for validation purposes and should be left unchanged.
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