Relate Family Counselling Review Form



CHILD FIRST REFERRAL FORMPlease use this form to access the Child First services listed below. Please complete as appropriate. It is vital to ensure that any referral has the approval of the Head teacher and the consent of family involved. Referrals should be emailed directly to the relevant project lead – details below. Referral Forms should be password protected to ensure confidentiality. CHILD FIRST CORE SERVICES (Funded by Child First)ServiceLead WorkersReferral RouteEmail Referral To:Family SupportJacky Curtis Amanda Rowe Complete this Referral Form and email to Jacky or Amanda.Amanda@.uk Jackie@.uk1:1 Primary Counselling Karen Ball Laura FryerStacey ColeEleanor CornellComplete this Referral Form and email to Alison Bennett.Alison@1:1 Secondary Conselling Kate WarburtonComplete this Referral Form and email to Kate Warburtonkate.warburton@.ukSpeech and LanguageC and D Speech TherapyCassie PiersonComplete a C&D Referral Form, downloadable HERE(). Email to Cassiecassie@cdspeechtherapy.co.uk?CHILD FIRST PLUS SERVICES (Spot Purchased by Child First Schools). All Service Prices are listed at ServceLead WorkersReferral RouteEmail Referral To:Play TherapyEmerging Butterflies Complete this Referral Form and email to Kimberley Hammond.kimberley.farrant@hotmail.co.uk07890 181893Yoga for Children and Young PeopleEmerging Butterflies,Complete this Referral Form and email to Kimberley Hammond.kimberley.farrant@hotmail.co.uk07890 181893Additional Speech TherapyC and D Speech TherapyCassie PiersonComplete a C&D Referral Form, downloadable HERE . (). Email to Cassiecassie@cdspeechtherapy.co.uk01206 700270Occupational TherapyRainbow TherapyComplete this Referral Form and email to Karen Bowden.rainbowtherapy4children@hotmail.co.ukPhysiotherapyLauren TwinComplete this Referral Form and email to Lauren.lauren.twin@live.co.ukThrive Licensed PractitionerButterfly Blue SolutionsComplete this Referral Form and email to Carolyn.carolyn@butterflybluesolutions.co.uk 07884 468332Additional Family Support WorkAmanda Rowe Jacky CurtisComplete this Referral Form and email to Jacky or Amanda.Amanda@.uk Jackie@.ukTranslation ServicesSacha BrakenburyPlease email Sacha to request supportsacha@.Section 1 Service Required e.g. Family SupportDate referral completedName and signature of head teacher approving the referralSection 2 - Referrer detailsName of person completing this formOrganisation (if applicable)If self-referring who told you about usContact TelephoneContact EmailAlternative contactSection 3 - Person being referred The main family contact needs to sign consent, unless the young person is 13 or over in which case they can sign themselves (see Section 6.)First NameSurname AgeDOBSchool/education or workplaceName of family contact signing consentRelationship to person referredContact telephone numbersFamily address including postcodeEmail address:Others family members First NameSurnameAgeRelationship or RoleAre there any learning needs to be considered for the person being referred?Are there any heritage, cultural or religious needs (include language) to be considered for the person being referred?Section 4 - Reason for referral Please indicate the issue(s) causing concern. Give details where possible.Risky behavioursAggressive behavioursChallenging behavioursRelationship breakdownsConflict within the familyEmotional distressSocial isolationOtherSection 5 – Other Agencies InvolvedPlease tick any agencies that the family has had contact with. Social CarePaediatrician/Clinical MedicalEducation WelfareEducational PsychologistBehaviour Support/SENCODrug and Alcohol ServicesChild and Family Consultation ServiceHealth Visitor/School Health ServicesVoluntary Organisations (e.g. Home Start)Mental HealthYouth Offending TeamSchool CounsellorOther (Pls give details)Section 6 - BackgroundPlease tell us what you or person referred has done to address this issue alreadyPlease tell us about other help that is in place now or has been in the past to address the issue/sHas any other help been requested for this problem (for example school, GP, health visitor, friend)Record here the views of the person being referred and what they want to get from the helpConcerns and/or risks: record here any concerns/risks we should know about before visiting the family/individual: E.g. is there a history of violence, unpredictable behaviour or specific home risks such as dangerous animals, history of drug use etc. Please call the relevant FSW directly if you wish to discuss further.Section 6 - Consent to access and share information This section should be signed by a family member with parental responsibility or a person over the age of 13. Please read carefully and then sign and date the form if you are in agreement. If you have concerns please discuss them with the person working with you. You can note any limit/restrictions in the box if required.I give my consent for this referral to be submitted.I agree that the person making/taking the referral may consult with other services/professionals for information about me/my/our child(ren) in order to help ensure that I/we access the correct support.I agree that personal information about me/us/my child(ren) may be shared with my child’s school to help evidence the effectiveness of the my/our involvement with this service, during and after my/our involvement. Where my data is part of a general project evaluation it will anonymised. I understand that I have the right to restrict what information may be shared and with whom.I understand that I may withdraw my consent to share information at any time but that might result in a reduction of services being available.I agree that I have been given a copy of the Child First Privacy Policy to keep and read. Information I do not want to be shared:Signed DateFor the Referrer/ProviderIs the person able to understand why their information may be shared and are they able to make a consent decision on this basis? (Please tick and complete A or B or C below).6054725889000A ) YES and I have explained to the person/their representative: Their right to withdraw consent at any time.Why we may need to share information and their right to restrict that information.Who we may need to contact to check for information – E.g. School, GP, Social Care, EWMHS, Early Help Hub and other VCS providers.That in some cases we may need to share information without consent in order to safeguard the vulnerable, to prevent crime and/or if ordered by a Court605472510414000B) I am unable to judge this and have referred this matter to…60547257937500C) No, because…Office use onlyAction √Dates/CommentsReferral acknowledged by emailReferral reviewed and accepted (and therefore logged on database)Referral allocated to relevant FSW/Counsellor/ServiceHelp requested does not deliver against the need identified Should be met by Level 1universal services Should be met by level 3 intensive services Should be met by level 4 intensive services Signposted to other Early Help ServiceOtherIf you have any questions in relation to your referral please feel free to contact Child First Trust.Www. 01206 252152 sacha@113665-5334000THIS PAGE MUST BE LEFT WITH THE FAMILYFrequently Asked Questions about Information Sharing.Why do you need to share my personal information? Sharing personal information helps us to work together to support children, young people and their families and carers. It is important to remember that if you don’t let us share your information, this could delay or prevent you from getting the help you need. We will only keep your information for as long as strictly necessary, after which time it will be secured destroyed or archived safely in accordance with the requirements of each project. You can find more detailed information on your specific programme by visiting - just look for the Data Protection tab.Can I choose what personal information is shared about my family and I?Yes, in almost all circumstances. Most of the time we will tell you what information we might need to pass on and who we need to pass it on to. The types of information to be shared may include: name, DOB, address, and relevant information to inform assessments and ongoing work. If there is something that you don’t want us to pass on about you then we won’t. Please tell the person working with you. But there are times when we don’t need to ask your permission to share information. Sometimes we HAVE to share personal information about you without asking your permission, for example:If we are worried about the safety of a child, young person or vulnerable adult;If we think that a crime may be prevented or found out by sharing it; orIf a court order is made in criminal or legal casesCan I change my mind about how you use and share my data?Yes, you can.You can ask us not to pass on your personal information to anyone else at any time.You can say no at first but you can always change your mind later on.Or, if you say choose to give your permission, you can also change your mind later on.What are the benefits of sharing my personal information? It will help us make sure that you get the right sort of help.You can quickly find out about the different types of help available to you.You won’t be asked for the same information lots of times.How might you share my personal information?We will only share your information with key, selected professionals and organisations, as outlined above. We will always do this is a safe and secure manner. Each Child First project shares data in slightly different ways – but always does so securely and only on a needs-led basis. You can see further details on way we may share your data on the Child First website at . On the Data Protection tab you will see a break down for each project. How will you store my data?All data is stored safely and securely. E.g. we use password-protected laptops, secure digital storage and back ups using Microsoft One Drive. Each project works slightly differently and you can see exactly how we will store you information on a particular project by visiting the Data Protection tab of the Child First website at . Can I see what data is held about me?Yes, if you want to check your own records or talk to someone about how safe and confidential your personal information is, you should talk to the person who is working with you. Alternatively, you can speak to the Child First Charity Manager, Sacha Brakenbury. Just call 01206 252152 or email sacha@What if I am not happy with how my data is being used?Please do speak to us if you have any concerns at all. We are committed to offering you a first rate service and we take the management of your data very seriously. You can contact Child First on 01206 252152 or email sacha@ if you have any concerns. For independent advice about data protection, privacy and data sharing issues, you can contact the Information Commissioner’s Office, Wycliffe House, Water Lane, Wilmslow, Cheshire SK9 5AF. Tel: 01625 545745 or 08456 306060 Fax: 01625 524510 Website: .uk ................
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