Starting Point request for support form

If you are concerned that a child is suffering or is at risk of significant harm please contact Call Derbyshire on tel: 01629 533190 immediately.


To request early help services for Derbyshire children and young people please complete this referral form.

If you have made a verbal referral and have been advised to confirm this in writing, please complete this referral form.

We'll share information with police and health colleagues to deal with enquiries more quickly − getting the right help to families at the right time. Any information provided by you will be treated in accordance with our privacy policy.

Please note if you are aware the child already has an allocated MAT worker or Social Worker please do not fill out this form and liaise directly with the allocated worker.

Please do not fill out this form if your request relates to an immediate child protection issue as this email box is only monitored 8am-6pm Monday − Friday, please call 01629533190 if your concern is urgent.

Starting point Request for support form

Note: Asterisks (*) indicate required information.

errorPlease correct the information in the fields highlighted below.
1. Details of the Family you wish to refer


First child in this family who you wish to refer





































Second child






Gender































Third child






Gender
































Fourth child






Gender
































Fifth child






Gender
































Sixth child






Gender
































Seventh child






Gender
































Eighth child






Gender
































Ninth child






Gender
































Tenth child






Gender
































2. Your contact details











3. Reason for Referral

If no please review the information on the previous page in relation to completing an early help assessment.








Please note if you have chosen no or not applicable on all the above boxes please consider calling the advice line prior to submitting this form on 01629535353

Please forward any paper /electronic copies of any assessments you have completed or if you are from a school please consider sending us your chronology to Starting Point Via
Secure email startingpoint@derbyshire.gcsx.gov.uk
Fax 01773 746236, or
by Post to:
Starting Point
Godkin House
2 Park Road
Ripley
DE5 3EF








Anonymity

There is an expectation that if you are a professional filling out this form you must inform the family and identify yourself as part of this process. Information regarding the identity of the person raising the concerns and requesting support will normally be shared with the family. If you consider that identifying you as the referrer will place you at a level of risk please explain below and a Social Worker will discuss this with you.



4. Other family or household members or significant others

e.g. Parents, step-parents, grand-parents, half siblings, step siblings or adult siblings.
















Second other family or household member or significant other

e.g. Parents, step-parents, grand-parents, half siblings, step siblings or adult siblings.







Gender









Third other family or household member or significant other

e.g. Parents, step-parents, grand-parents, half siblings, step siblings or adult siblings.







Gender









Fourth other family or household member or significant other

e.g. Parents, step-parents, grand-parents, half siblings, step siblings or adult siblings.







Gender









Fifth other family or household member or significant other

e.g. Parents, step-parents, grand-parents, half siblings, step siblings or adult siblings.







Gender









Sixth other family or household member or significant other

e.g. Parents, step-parents, grand-parents, half siblings, step siblings or adult siblings.







Gender









Seventh other family or household member or significant other

e.g. Parents, step-parents, grand-parents, half siblings, step siblings or adult siblings.







Gender









Eighth other family or household member or significant other

e.g. Parents, step-parents, grand-parents, half siblings, step siblings or adult siblings.







Gender









Ninth other family or household member or significant other

e.g. Parents, step-parents, grand-parents, half siblings, step siblings or adult siblings.







Gender









Tenth other family or household member or significant other

e.g. Parents, step-parents, grand-parents, half siblings, step siblings or adult siblings.







Gender









5. Other Professionals/Agencies involved








second agency involved








third agency involved








fourth agency involved








6. Stronger Families Safer Children Safety and Well-being Grid





7. Threshold Scaling

Using the information you have provided please tick the safety and wellbeing scale below to indicate what level of need you consider this referral suggests

Where need is relatively low and where individual services and universal services may be able to address the child’s needs without the involvement of other services



Where a range of early help services may be required. Co-ordinated through an early help assessment (previously known as CAF) where there are concerns for a child’s wellbeing or a child’s needs are not clear, not known or not being met



Where without the intervention the child would become at a risk of significant harm or the needs are such that without intervention the child’s health or development would be seriously impaired. Help is provided as a ‘child in need’ under section 17 of the Children Act 1989 via a specialist in-depth assessment and following this at least initial co-ordination of services via the social worker.”



If you are referring a child who is at risk of significant harm please call 01629533190 immediately, you may be advised to complete this form to confirm your telephone referral

Where there is reasonable cause to suspect a child is suffering or likely to suffer significant harm because of abuse or neglect. Under Section 47 of the Children Act 1989 local authority children’s social care must make enquiries and decide if any action must be taken to protect the child



8. Any other issues that you are aware of

















If you experience any problems with this form please contact contact.centre@derbyshire.gov.uk and quote form ID: ILF/512/09