Homestartmanchestercom.files.wordpress.com



Home-Start Manchester Request for Volunteer Support

Please note we can only accept referrals where there is at least one child under 5 living in the family home. ALL sections of the form must be completed - any incomplete forms will be returned for full completion. Consent of the family MUST be sought prior to the referral being submitted and the referral form signed by the parent / carer.

Please indicate the type of support required: HOME-VISITING VOLUNTEER PIMH VOLUNTEER

|DATE OF REFERRAL |FAMILY SURNAME |REFERRERS NAME |REFERRERS JOB TITLE |

| | | | |

|FAMILY ADDRESS |REFERRERS ADDRESS |

| | |

| | |

| | |

| | |

|POSTCODE: | |

|EMAIL: |E-MAIL: |

|FAMILY CONTACT NO: |REFERRERS CONTACT NO: |

| | |

1. PARENTS / CARERS DETAILS

|FULL NAME |D.O.B |NATIONALITY & IMMIGRATION STATUS |DISABILITY Y/N |RELATIONSHIP TO CHILDREN |

| | | | | |

| | | | | |

2. CHILDREN’S DETAILS (Please list all those under 16 - eldest child first)

|NAME |D.O.B |GENDER |NATIONALITY |DISABILITY/ ADDITONAL NEEDS |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

3. HAS THE FAMILY RECEIVED HOME-START SUPPORT BEFORE? YES/NO

|DATE |HOME-START AREA |

| | |

4. COMMUNICATION

|POTENTIAL BARRIER |DETAIL |

|Languages used | |

|Literacy | |

|Interpreter needed | |

|Learning Difficulties / Disability | |

5. INVOLVEMENT WITH OTHER SERVICES:

|AGENCY |YES / NO / PREVIOUS |TEAM/ LEAD PROFESSIONAL contact details (name, |Does the family engage well |

| | |telephone and email) |with these services? |

| | | |Y N |

|GP |YES / NO / PREVIOUS | | | |

|Health Visitor |YES / NO / PREVIOUS | | | |

|Pre-school/school setting |YES / NO / PREVIOUS | | | |

|Early Help Services: please specify |YES / NO / PREVIOUS | | | |

|which services | | | | |

|Adult or child Mental Health Services: |YES / NO / PREVIOUS | | | |

|please specify which services | | | | |

|Complex families: please specify which |YES / NO / PREVIOUS | | | |

|team | | | | |

|Vulnerable Babies |YES / NO / PREVIOUS | | | |

|Children’s Services Social Care |YES / NO / PREVIOUS | | | |

|Drug and alcohol services |YES / NO / PREVIOUS | | | |

|Voluntary agencies: please specify |YES / NO / PREVIOUS | | | |

|Others: Specify | | | | |

| | | | | |

| | | | | |

| | | | | |

6. EARLY HELP ASSESSMENTS, SPECIALIST CASE PLANNING, CHILD IN NEED, CHILD PROTECTION

CURRENT or PREVIOUS Please provide details below of any plans relating to the family.

|Plan Type |START |END |LOCAL AUTHORITY |LEAD PROFESSIONAL |Relevant to which child? |

| | | | | | |

| | | | | | |

| | | | | | |

7. PIMH PROJECT (Please tell us why you feel your family would benefit from PIMH support - see guidance notes for further information).

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

8. WHAT IS WORKING WELL FOR THE FAMILY?

Please tell us about the family’s wider network i.e. the support they have from family, friends and the local community e.g. childcare; positive supportive relationships; involvement in community groups; paid / voluntary work.

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

9. HOW WILL THE FAMILY BENEFIT FROM A HOME-START VOLUNTEER

|HOME-START AREAS OF SUPPORT |WHAT COULD BE BETTER? |HOW DO YOU THINK A VOLUNTEER CAN HELP? |

|PARENTING SKILLS |

|Managing children’s behaviour | | |

| | | |

| | | |

| | | |

| | | |

|Parental involvement in children’s | | |

|development and learning | | |

| | | |

| | | |

| | | |

|PARENT’S WELL BEING |

|Parents physical health | | |

| | | |

| | | |

| | | |

|Parents mental health | | |

| | | |

| | | |

| | | |

|Family isolation | | |

| | | |

| | | |

| | | |

|Parents self esteem | | |

| | | |

| | | |

| | | |

|CHILDREN’S WELL BEING |

|Children’s physical health | | |

| | | |

| | | |

|Children’s mental health | | |

| | | |

| | | |

|Being ready for school | | |

| | | |

| | | |

|FAMILY MANAGEMENT |

|Managing the household budget | | |

| | | |

| | | |

|Day to day running of the home | | |

| | | |

| | | |

| | | |

|Accessing healthy lifestyle and diet | | |

| | | |

| | | |

|Coping with multiple children under 5 | | |

| | | |

| | | |

|Family conflict | | |

| | | |

| | | |

|Support to use other services | | |

| | | |

| | | |

|Other | | |

| | | |

| | | |

10. RISK ASSESMENT: Please highlight any issues we need to be aware of when visiting the home. NB, if you consider it is not safe for a volunteer to visit the family alone, please don’t proceed with this referral.

|AREA OF POTENTIAL CONCERN |Current Issue |Previous Issue |No Issue |DETAILS |

|Substance Misuse | | | | |

| | | | | |

|Smoking in the home | | | | |

| | | | | |

|Significant offending | | | | |

| | | | | |

|Aggressive / violent behaviour | | | | |

|Self-Harm | | | | |

| | | | | |

|Domestic Abuse inc. Physical, emotional, sexual, | | | | |

|financial | | | | |

|Inappropriate sexual behaviour towards others | | | | |

|Risk related to pets eg large dogs | | | | |

| | | | | |

|Involvement with guns and gangs | | | | |

| | | | | |

|Other people present in the home | | | | |

| | | | | |

|Home environment: cleanliness, clutter | | | | |

| | | | | |

|Access issues to the home e.g. first floor flat | | | | |

| | | | | |

|Behaviour of older children in the home | | | | |

| | | | | |

|Other | | | | |

Referrer Signed:…… …………………………………………………… Date: ………………………………………

Parent Signed:…………………………………………………………………..Date:…………………………………………

Please return your fully completed and signed form:

By e-mail to info@.uk

By post to Woodville Resource Centre, Shirley Road, Cheetham, Manchester, M8 0NE

If you want to discuss the referral you can contact us by phone on 0161 721 4493

HOME START REFERRAL FORM GUIDANCE FOR REFERRER

This form asks for all the information we need in order to make a decision about prioritising families for initial home visits. Please complete each section of the form. If a section is not applicable, please mark N/A and go to the next question.

Please ensure you have discussed in detail the support Home-Start is able to provide and subsequently feel confident

a) the family are ready to engage with our support

b) Home-Start is the right service for the family

c) The family will be happy to consent to the sharing of information with us to provide the service

Sections 1 and 2: Please provide all relevant contact information for yourselves and the family you are referring.

Section 3: It is helpful for us to know if the family have previously had Home-Start support, so we can access their records from colleagues.

Section 4: It helps us to know in advance if language or communication support is required as we have limited funds for interpreters which we may use at the Initial Visit only. We have a very limited number of volunteers who can speak more than one language. Please let us know if we are able to utilise your agency’s interpreting resource.

Sections 5 and 6: It is important we are made aware of current and previous involvement with existing services, including how well the family engage, so we can share information, assess a family’s progress, and identify their level of need. It is very helpful to have all contact details, including telephone number and email of all professionals involved. Please note that due to the volunteer led nature of the support we offer, we are unable to work with families on Child Protection, however, families on CIN plans will be considered on an individual basis.

Section 7: The Parent Infant Mental health project (PIMH) supports families where there is a child under 2 (or with a child that hasn’t been born yet) and where the parent has low to moderate Mental Health difficulties. The support focusses on encouraging and developing relationships between the parents and their baby.

All volunteers offering PIMH support have undergone specific PIMH training.

Section 8: Home-Start is a strength-based, solution-focused service. Our starting point is to identify what is currently working well for a family, and we seek to build on families’ strengths.

Section 9: This is the main body of the referral. Please tell us what the family want to achieve as a result of Home-Start’s support and the type of support the family would need. How do you think a weekly visit from a Home-Start volunteer might make a difference to the family and what resources do the family have to contribute to achieving the outcomes? This section helps us identify if Home-Start has the resources, experience and expertise to support the family.

Section 10: We need to know that the family home is safe for volunteers to visit unaccompanied on a weekly visit. Please advise us of any issues which may threaten their safety or wellbeing

Finally, please check all sections are completed and that the form is signed by yourself as the referrer and the parent requiring support.

Please send us your completed form by e-mail to info@.uk ensuring it is password protected or using egress or another secure method.

Your referral will be acknowledged on receipt and estimated waiting list duration will be provided. Please also note we do not make contact with the family until we have a suitable volunteer available and are ready to carry out our initial visit.

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download