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**

No of children being referred

Details of child being referred

First Name *

Last Name *

M/F *

Female

Male

Not known

Have they been born yet?

Yes

DOB

Day

Month

Year

Expected due date

Day

Month

Year

Ethnicity

Disability / Additional needs

If applicable please give brief details of any disability or additional needs in relation to child or parent.

NHS Number (child) *

Early Help Plan number (child)

Sure Start registered

Any other children in Family?

Other Children In Family

Name

M/F

DOB

Day

Month

Year

Name

M/F

DOB

Day

Month

Year

Name

M/F

DOB

Day

Month

Year

Name

M/F

DOB

Day

Month

Year

Name

M/F

DOB

Day

Month

Year

Child 2

First Name

Last Name

Gender

Female

Male

Not known

DOB

Day

Month

Year

Expected due date

Day

Month

Year

Ethnicity

Disability/Additional needs

NHS Number

Early Help Plan number

Sure Start registered

Child 3

First Name

Last Name

Gender

Female

Male

Not known

DOB

Day

Month

Year

Expected due date

Day

Month

Year

Ethnicity

Disability/Additional needs

NHS Number

Early Help Plan number

Sure Start registered

Additional Parent/Carer (Adult 2) - Click here to add another adult

Relationship to child

Title

First Name

Last Name

M/F

DOB

Day

Month

Year

NHS Number Adult 2 *

Ethnicity

Single parent

Yes

This adult lives

Street Address

Street Address Line 2

Street Address Line 3

City

Postcode

Mobile

Home Phone

First Name

Last Name

Phone Number

Address 1

Address 2

City

Postcode

Health Visitor

First Name

Last Name

Phone Number

Address 1

Address 2

City

Postcode

Lead Professional (Community Family Hub)

First Name

Last Name

Phone Number

Address 1

Address 2

City

Postal Code

Contact with any other agencies

Adult Mental Health worker

First Name

Last Name

Phone Number

CAMHS worker

First Name

Last Name

Phone Number

Childrens Centre worker

First Name

Last Name

Phone Number

Child protection worker

First Name

Last Name

Phone Number

Court welfare worker

First Name

Last Name

Phone Number

Domestic Violence

First Name

Last Name

Phone Number

Drugs Project

First Name

Last Name

Phone Number

Fostering/Adoption

First Name

Last Name

Phone Number

Looked after Children

First Name

Last Name

Phone Number

Midwife

First Name

Last Name

Phone Number

Nursery

First Name

Last Name

Phone Number

Obstetrics

First Name

Last Name

Phone Number

Probation Services

First Name

Last Name

Phone Number

Social Services

First Name

Last Name

Phone Number

Substance misuse

First Name

Last Name

Phone Number

Teenage Agencies

First Name

Last Name

Phone Number

Voluntary Agencies

First Name

Last Name

Phone Number

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.

Referrer - Your details

First Name *

Last Name *

Job Title *

Organisation *

Address *

City *

Postcode *

Telephone number *

Referer Email *

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.

I agree to these terms *

Yes

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Referral form

Contact with any other agencies

Stresses on the parent child relationship

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

Data Protection Act 1998

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Referral form

Contact with any other agencies

Stresses on the parent child relationship

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

Data Protection Act 1998