Liverpool City Council

Consent confirmation

Confirmation

I confirm that the parent/carer and (where appropriate) the child has given consent to an Early Help referral. I confirm that they give permission for this information to be shared with other professionals to plan what help is needed.
I have explained to the parent/carer that their information will be processed as per the Data Protection Act 1988 and the General Data Protection Regulations 2018.
I have explained to the parent/carer that if there are safeguarding concerns identified then the practitioner will follow Liverpool's Local Safeguarding Children Partnership (LSCP) reporting procedures.

You must confirm all of the above to be able to proceed with the referral.

Referrer

First name

Last name

Job role

Team

Service/Organisation

Address

Telephone

EXT number

Parent Carer details

Parent details To add parent/carer, click 'Add item'

First name

Last name

Date of birth

Relationship to child

Ethnicity

Nationality

Language spoken

Disability

Yes
No

If yes, details of disability - optional

Gender

Male
Female
Other

Address

Postcode

Use the Lookup Postcode button to find the address.

If you cannot find the address, please enter it manually

Phone

Add item

Will an interpreter be required

Yes
No

Referral details

When completing this section please ensure that you

Include the views of the parent/carer and child
Use the level of need guidance

Outline the reason for the request for Early Help support and the needs that you have identified for the family Please note that if insufficient information is provided the referral will be returned to you and this will delay your request for support.

What has led to the family asking for Early Help support? Please provide an overview of the family worries or issues of concern. What is the impact on the children within this family? What does the family need support with and how will this help assist with the concerns you have identified? What are the worries for the child/ren and family, should the concerns identified not be addressed?

What is working well for the child and their family? Please detail what existing support is currently being provided from professionals, agencies and/or family members. What are the families' strengths? What are the child/ren and families views?

Before you submit this form please review your answers below. If you need to change anything, use the 'previous' button on the bottom left to go back to a section. Then submit the form by selecting the 'Submit button' at the bottom of this page

Referral for Early Help