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Whoops and Parenting programmes
Is this a self referral?
*
Yes
No
Referrer
First Name
*
Last Name
*
Phone Number
*
Email
*
Parent information
First Name
Last Name
Gender
- None -
Female
Male
Other
Not known
Birth Date
Day
Day
1
2
3
4
5
6
7
8
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10
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12
13
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19
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31
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Year
Year
1919
1920
1921
1922
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
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1971
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1990
1991
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1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
Ethnicity
- None -
White - English/Welsh/Scottish/Northern Irish/British
White - Irish
White - Gypsy or Irish Traveller
White - Any other White background
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Asian
Mixed - Any other mixed/multiple ethnic background
Asian/Asian British - Indian
Asian/Asian British - Pakistani
Asian/Asian British - Bangladeshi
Asian/Asian British - Chinese
Asian/Asian British - Any other Asian background
Black/African/Caribbean/Black British - African
Black/African/Caribbean/Black British - Caribbean
Black/African/Caribbean/Black British - any other background
Other ethnic group - Arab
Other ethnic group - any other ethnic group
Not stated
Ethnicity Other
Pregnant?
Yes
No
Expected due date
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Year
Year
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
2046
2047
2048
2049
2050
2051
2052
2053
2054
2055
2056
2057
2058
2059
2060
2061
2062
2063
2064
2065
2066
2067
2068
2069
Email
Phone Number
Single Parent
Yes
No
Don't know
Are you currently in employment
Yes
No
Legal Status
- None -
Early Help Plan
Child Protection
Child In Need
To Be Initiated
Do you have any medical conditions we should be aware of?
Yes
No
Medical conditions information
Street Address
Street Address Line 2
Street Address Line 3
Ward
Arthur's Hill
Benwell and Scotswood
Blakelaw
Byker
Callerton and Throckley
Castle
Chapel
Dene and South Gosforth
Denton and Westerhope
Elswick
Fawdon and West Gosforth
Gosforth
Heaton
Kenton
Kingston Park South and Newbiggin Hall
Lemington
Manor Park
Monument
North Jesmond
Ouseburn
Parklands
South Jesmond
Walker
Walkergate
Ward outside of Newcastle
West Fenham
Wingrove
City
Postal Code
Please only add details of children who will be recieving support from Children North East.
Any other children in Family
- None -
N/A
1
2
3
4
5
6
Child
First Name
Last Name
Birth Date
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Year
Year
1919
1920
1921
1922
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
Ethnicity
- None -
White - English/Welsh/Scottish/Northern Irish/British
White - Irish
White - Gypsy or Irish Traveller
White - Any other White background
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Asian
Mixed - Any other mixed/multiple ethnic background
Asian/Asian British - Indian
Asian/Asian British - Pakistani
Asian/Asian British - Bangladeshi
Asian/Asian British - Chinese
Asian/Asian British - Any other Asian background
Black/African/Caribbean/Black British - African
Black/African/Caribbean/Black British - Caribbean
Black/African/Caribbean/Black British - any other background
Other ethnic group - Arab
Other ethnic group - any other ethnic group
Not stated
Ethnicity Other
Legal Status
Early Help Plan
Child Protection
Child In Need
To Be Initiated
Do you have any medical conditions we should be aware of?
Yes
No
Medical conditions information
Sibling 1
First Name
Last Name
Ethnicity
- None -
White - English/Welsh/Scottish/Northern Irish/British
White - Irish
White - Gypsy or Irish Traveller
White - Any other White background
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Asian
Mixed - Any other mixed/multiple ethnic background
Asian/Asian British - Indian
Asian/Asian British - Pakistani
Asian/Asian British - Bangladeshi
Asian/Asian British - Chinese
Asian/Asian British - Any other Asian background
Black/African/Caribbean/Black British - African
Black/African/Caribbean/Black British - Caribbean
Black/African/Caribbean/Black British - any other background
Other ethnic group - Arab
Other ethnic group - any other ethnic group
Not stated
Ethnicity Other
Legal Status
Early Help Plan
Child Protection
Child In Need
To Be Initiated
Do you have any medical conditions we should be aware of?
Yes
No
Medical conditions information
Sibling 2
First Name
Last Name
Ethnicity
- None -
White - English/Welsh/Scottish/Northern Irish/British
White - Irish
White - Gypsy or Irish Traveller
White - Any other White background
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Asian
Mixed - Any other mixed/multiple ethnic background
Asian/Asian British - Indian
Asian/Asian British - Pakistani
Asian/Asian British - Bangladeshi
Asian/Asian British - Chinese
Asian/Asian British - Any other Asian background
Black/African/Caribbean/Black British - African
Black/African/Caribbean/Black British - Caribbean
Black/African/Caribbean/Black British - any other background
Other ethnic group - Arab
Other ethnic group - any other ethnic group
Not stated
Ethnicity Other
Legal Status
Early Help Plan
Child Protection
Child In Need
To Be Initiated
Do you have any medical conditions we should be aware of?
Yes
No
Medical conditions information
Sibling 3
First Name
Last Name
Ethnicity
- None -
White - English/Welsh/Scottish/Northern Irish/British
White - Irish
White - Gypsy or Irish Traveller
White - Any other White background
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Asian
Mixed - Any other mixed/multiple ethnic background
Asian/Asian British - Indian
Asian/Asian British - Pakistani
Asian/Asian British - Bangladeshi
Asian/Asian British - Chinese
Asian/Asian British - Any other Asian background
Black/African/Caribbean/Black British - African
Black/African/Caribbean/Black British - Caribbean
Black/African/Caribbean/Black British - any other background
Other ethnic group - Arab
Other ethnic group - any other ethnic group
Not stated
Ethnicity Other
Legal Status
Early Help Plan
Child Protection
Child In Need
To Be Initiated
Do you have any medical conditions we should be aware of?
Yes
No
Medical conditions information
Sibling 4
First Name
Last Name
Ethnicity
- None -
White - English/Welsh/Scottish/Northern Irish/British
White - Irish
White - Gypsy or Irish Traveller
White - Any other White background
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Asian
Mixed - Any other mixed/multiple ethnic background
Asian/Asian British - Indian
Asian/Asian British - Pakistani
Asian/Asian British - Bangladeshi
Asian/Asian British - Chinese
Asian/Asian British - Any other Asian background
Black/African/Caribbean/Black British - African
Black/African/Caribbean/Black British - Caribbean
Black/African/Caribbean/Black British - any other background
Other ethnic group - Arab
Other ethnic group - any other ethnic group
Not stated
Ethnicity Other
Legal Status
Early Help Plan
Child Protection
Child In Need
To Be Initiated
Do you have any medical conditions we should be aware of?
Yes
No
Medical conditions information
Sibling 5
First Name
Last Name
Ethnicity
- None -
White - English/Welsh/Scottish/Northern Irish/British
White - Irish
White - Gypsy or Irish Traveller
White - Any other White background
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Asian
Mixed - Any other mixed/multiple ethnic background
Asian/Asian British - Indian
Asian/Asian British - Pakistani
Asian/Asian British - Bangladeshi
Asian/Asian British - Chinese
Asian/Asian British - Any other Asian background
Black/African/Caribbean/Black British - African
Black/African/Caribbean/Black British - Caribbean
Black/African/Caribbean/Black British - any other background
Other ethnic group - Arab
Other ethnic group - any other ethnic group
Not stated
Ethnicity Other
Legal Status
Early Help Plan
Child Protection
Child In Need
To Be Initiated
Do you have any medical conditions we should be aware of?
Yes
No
Medical conditions information
Sibling 6
First Name
Last Name
Ethnicity
- None -
White - English/Welsh/Scottish/Northern Irish/British
White - Irish
White - Gypsy or Irish Traveller
White - Any other White background
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Asian
Mixed - Any other mixed/multiple ethnic background
Asian/Asian British - Indian
Asian/Asian British - Pakistani
Asian/Asian British - Bangladeshi
Asian/Asian British - Chinese
Asian/Asian British - Any other Asian background
Black/African/Caribbean/Black British - African
Black/African/Caribbean/Black British - Caribbean
Black/African/Caribbean/Black British - any other background
Other ethnic group - Arab
Other ethnic group - any other ethnic group
Not stated
Ethnicity Other
Legal Status
Early Help Plan
Child Protection
Child In Need
To Be Initiated
Do you have any medical conditions we should be aware of?
Yes
No
Medical conditions information
Key Information
Programme or course interested in?
DARE domestic abuse recovery and education or / F.A.S.T families are stronger together
Todays Teens / Tomorrows Teens
Safeguarding Futures
Caring Dads
Preparing for Baby / Babies Here
WHOOPS
Youth Music
Is the family in receipt of any of the following benefits:
Income support
Job seekers allowance
Universal credit
Disability living allowance (care or mobility component for a disabled child)
Safety proof purchase scheme (not in receipt of the above benefits and is self paying
Purchase of equipment
Tenancy
YHN Tennent
Private landlord tennet
Other (please specify)
Dwelling type
Semi detached
Detached
Flat
Maisonette
Terrace
Bedrooms
1
2
3
4
5
Has an injury occurred in home?
Yes
No
Permission to fit
Yes
No
What are the reasons for referral?
Parent/Carer unable to afford
Lack of child safety awareness
Previous history of accidents
What are your concerns regarding home safety for this family?
Home safety checks are carried out as part of the service. Would the family benefit from a home safety champion to deliver home safety and first aid advice in the home?
Yes
No
What is the intended outcome
How did you hear about Children North east
Do you / Does the parent consent to data being collected for the purpose of monitoring
Yes
No
