ࡱ> <>9:; @ bjbj{{ ;gbbbv^R^R^R8RjSvLBV&hXpXXX]0^:^RHbN`]]"N`N`XXeeeN`p8X8XeN`eesXJX6V uA^R`dˑ({t 0L"aPvvbJ^Z^@e^4_6J^J^J^vv6<D:edvv<CHILDRENS SOCIAL CARE Inter-Agency Referral FormThis form should be used to make a referral to Childrens Social Care. (Where you believe there is an immediate risk of significant harm please make the referral by telephone and confirm in writing within 48hours) For guidance on making an appropriate referral please see: Birmingham Safeguarding Procedures Section 3 www.lscbbirmingham.org.uk Common Assessment Framework Levels of Need (Windscreen Model)  HYPERLINK "http://www.birmingham.gov.uk" www.birmingham.gov.uk/CAF  Name of person completing referral Relationship to child being referred Date TimeTel No.AgencyAddress EmailFax No. Child / Young Persons DetailsFamily NameFirst NamesDoBGenderMale  FORMCHECKBOX Female  FORMCHECKBOX Unborn  FORMCHECKBOX Address Home Tel No.Mobile No. ethnicityAsian Other FORMCHECKBOX Chinese FORMCHECKBOX Kashmiri FORMCHECKBOX Vietnamese FORMCHECKBOX Bangladeshi FORMCHECKBOX Data Not on File FORMCHECKBOX Mixed Parentage FORMCHECKBOX White Other FORMCHECKBOX Black Other FORMCHECKBOX Gujarati FORMCHECKBOX Pakistani FORMCHECKBOX White UK FORMCHECKBOX Black African FORMCHECKBOX Indian FORMCHECKBOX Refused FORMCHECKBOX Yemeni FORMCHECKBOX Black African Caribbean FORMCHECKBOX Irish FORMCHECKBOX Sikh FORMCHECKBOX Other FORMCHECKBOX If Other category chosen, please give details:religionNone FORMCHECKBOX Rastafarian FORMCHECKBOX Jehovahs Witness FORMCHECKBOX Protestant FORMCHECKBOX Muslim FORMCHECKBOX Seventh Day Adventist FORMCHECKBOX Roman Catholic FORMCHECKBOX Sikh FORMCHECKBOX Other FORMCHECKBOX Eastern Orthodox FORMCHECKBOX Hindu FORMCHECKBOX Refused FORMCHECKBOX Jewish FORMCHECKBOX Buddhist FORMCHECKBOX Data Not on File FORMCHECKBOX If Other category chosen, please give details:First LanguageInterpreter Required? YES  FORMCHECKBOX  NO  FORMCHECKBOX GP School Describe the subject childs physical characteristics e.g. Colour of Eyes, Hair, Skin, Approx Height and Weight and any Obvious distinguishing marks This informAtion is required to ensure the appropriate child is identified for assessment (Serious CAse Review recommendation - 2009)  Details of referralDescribe the identified cause for concern  On what evidence / information is your concern is based? What action have you / your agency taken to date to address this specific concern? (If you or your agency have already completed a CAF please attach)  Family ContextOutline your agencys role / service provided to the child and or family. Confirm how long you have been involved and include any history of concerns Outline your knowledge of the childs needs and parents capacity to meet these. Include any family and environmental factors that impact on childs need and parents capacity. For guidance see Framework for Assessment of Children In Need and their Families 2004 www.the-stationary-office.co.uk/doh/facn/facn.htm  Family Composition and household membersNameGenderDoB/AgeRelationship to subject childSchool (include UPN if known) Nursery Childrens CentreGP     SIGNIFICANT OTHERS NOT OF THE HOUSEHOLDNameGenderDoB/AgeRelationship to subject childDoes this person hold parental responsibility?Is this person a known risk to children - PPRC?     Consent & confidentialityIs the parent aware of the referral? YES  FORMCHECKBOX  NO  FORMCHECKBOX Has the parent given consent to the referral being made? YES  FORMCHECKBOX  NO  FORMCHECKBOX If the answer to either of the above is No please provide an explanation Is any information contained in this referral to remain confidential from the subject child and family? If so outline specific information to remain confidential and reasons. NB details of referrer if a professional person cannot be held as confidential save in exceptional circumstances        Aug 2009Page  PAGE 4 of  NUMPAGES 5 Aug 2009Page  PAGE 5 of  NUMPAGES 5   (Birmingham Childrens Young People & Families Directorate IAR1 Aug 2009Personal information given to us is subject to the Data Protection Act 1998 and will be used to assess your needs and provide services if you are eligible. Birmingham City Council reserves the right to share this information with external agencies who assist in the provision of services and any government departments who have a statutory right to such disclosure.Page  PAGE 1 of  NUMPAGES 5 +012Bmsty B C D N O [ \ q w x xkakakakRkakhT'hT'0JOJQJ^Jh5 ,OJQJ^JhUhhROJQJ^J hUh5 ,hhRhUhhR5CJaJh5 , hUhhRhUhE~5B*CJ\ph+hUhE~5B* CJOJQJ\^Jphff+hUhhR5B*CJ(OJQJ\^Jph33%h05B*CJ(OJQJ\^Jph33+hUhE~5B*CJ(OJQJ\^Jph3312y C D r  $hP$If^ha$gd5 ,$ & FP$Ifa$gdhR $IfgdhR $$Ifa$gdhR7kd$$Ifsq#c4 sa $$Ifa$gd0        ! " ? 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