1Consent 2Referrer Details 3Parent / Carer details 4Child details 5Reason for Early Help Referral 6Summary Progress Step 1 Consent 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. No information is required, please proceed to the next page. Referrer Details Referrer First name Last name Job role Team Service/Organisation Address Telephone EXT number Email No information is required, please proceed to the next page. Parent / Carer details Parent Carer details Parent details To add parent/carer, click 'Add item' First name Last name Date of birth Relationship to child Ethnicity -- Please Select -- White – British Not known at this stage Black background Any Other Ethnic Group Mixed – Any other mixed background Asian background Asian/Asian British – Any other Asian/Asian British - Bangladeshi Asian/Asian British - Indian Asian/Asian British - Pakistani Black/Black British - African Black/Black British – Any other Black/Black British - Caribbean Chinese Mixed – White and Asian Mixed – White and Black African Mixed – White and Black Caribbean White – Any other white background White – Gypsy/Roma White – Irish White – Traveller of Irish Heritage Nationality Language spoken Disability Yes No If yes, details of disability (optional) Gender Male Female Other Address Postcode Find Address Loading addresses... Select Address -- Please select -- Address line 1 Address line 2 (optional) City Postcode Clear postcode/address 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 No information is required, please proceed to the next page. Child details Childrens details Child details To add siblings or step-siblings, click 'Add' First name Last name Date of birth or due date Gender Female Male Other Ethnicity -- Please Select -- White – British Not known at this stage Black background Any Other Ethnic Group Mixed – Any other mixed background Asian background Asian/Asian British – Any other Asian/Asian British - Bangladeshi Asian/Asian British - Indian Asian/Asian British - Pakistani Black/Black British - African Black/Black British – Any other Black/Black British - Caribbean Chinese Mixed – White and Asian Mixed – White and Black African Mixed – White and Black Caribbean White – Any other white background White – Gypsy/Roma White – Irish White – Traveller of Irish Heritage Nationality Language spoken Disability Yes No If yes, details of disability (optional) Does the child attend a nursery, school or centre? Yes No Name and address of nursery/school or centre (if applicable) (optional) Add item GP name/address GP telephone number (optional) Are there any other services supporting the family? Yes No Details of services To add another service, click 'Add item' Name of service Telephone number of service (optional) Add item Which of the following affect adults or children within the family (please tick all that apply) Mental Health issues Drug issues Alcohol issues Domestic abuse/violence Neglect Learning difficulties Child Exploitation (sexual/criminal) Discrimination / Racism Poverty Housing Other If other, please state No information is required, please proceed to the next page. Reason for Early Help Referral 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? No information is required, please proceed to the next page. 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 Loading form summary... PreviousNext