Referral form

Supporting first relationships. Request for the NEWPIP Services. *** Confidential *** Please complete as much of this family information as possible. We expect this referral to have been discussed and agreed with the parent(s). **Please be aware that you will need NHS numbers for the main parent and child (unless unborn), to complete this referral form**

Details of child being referred
If applicable please give brief details of any disability or additional needs in relation to child or parent.
Other Children In Family
Child 2
Child 3
Details of Parent/Carer (Adult 1)
Other People living in household
GP
Health Visitor
Please select all additional agencies:
Lead Professional (Community Family Hub)

Contact with any other agencies

Adult Mental Health worker
CAMHS worker
Childrens Centre worker
Child protection worker
Court welfare worker
Domestic Violence
Drugs Project
Fostering/Adoption
Looked after Children
Midwife
Nursery
Obstetrics
Probation Services
Social Services
Substance misuse
Teenage Agencies
Voluntary Agencies

NEWPIP aims to support the relationship between caregiver(s) and baby or toddler when this is likely to become, or is already, under stress.  The age range for working with a family is from bump to 24 months.  Please use the risk factor check list on page 4 of this referral form as a guide to assist you to clarify potential stressors on the caregiving relationship and to give a profile of the family’s’ vulnerabilities.

Where there are planned or ongoing child protection issues, including multi-agency assessments, we will liaise with other agencies to consider the appropriateness of referral at that time.  If a caregiver has mental health difficulties we would expect support to already be in place from adult services.  Please give as much information as possible and feel free to either write a separate supporting letter or telephone us as well.   

During sessions video will usually be taken as part of the work.  This provides useful feedback to support parents in understanding what happens between them and their child.  We use video as it is the best way of looking at and assessing what goes on in everyday play and interaction in order to highlight different aspects of parenting.  Please explain this to the parent (s).  This does not imply that they have given permission in advance.  We will ask parents to sign a form to give permission before any filming takes place, and they have the choice as to whether or not they wish to do this.

Referral details

(Information About Your Concerns: Parent / Carer’s Mental Health; Any Current Child Protection Proceedings; Social Support Network; Any Other Relevant Information?)

Please use the ‘Stresses on the parent child relationship Checklist’ below

Please indicate your opinion as to the Parent/Carers motivation and readiness to engage.

SUMMARISE TWO MAIN REASONS FOR REFERRAL

Stresses on the parent child relationship

It helps the team in considering referrals if the checklist below is used as a guide to assist you in thinking about potential stressors on the caregiving relationship and to give a profile of the family’s’ vulnerabilities.  Many known risk factors put a strain on the baby-parent relationship. An analysis of these allows intervention to be considered at a preventative level, before the infant’s quality of attachment has been compromised. Usually, the presence of four to six moderate risk factors is significant, but individual factors can sometimes also merit attention. 
However, there are certain serious conditions that, in some circumstances, call for interventions on their own. These have been show in yellow below.
 

Referrer - Your details

DECLARATION (to confirm consent has been given by parent please)

Data Protection Act 1998 

Children North East is required by the Data Protection Act 1998 to obtain consent from service users to have access to their personal information and to share that information with other agencies. 

Can you please confirm that you have discussed this referral with the parent(s) and that they have given consent for their information to be passed to the NEWPIP service and for NEWPIP to contact the professionals or agencies named on the referral form.
        
   

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