SSD Case Numbers Date referral received

Is the parent/carer aware of the referral? Yes n No n Re-Referral n

Child/Young Personís name, address and responsible LA

Family name Forenames Dob Gender


Postcode Tel.

Current address if different from above

Postcode Tel.

SSD Team Responsible local authority

Child/Young Personís principal carers

Name Relationship to child/young person Parental Responsibility

Yes n No n

Yes n No n

Referred by Agency/rel. to child/young person


Postcode Tel.

Does referrer wish to remain anonymous Yes n No n

Other household members (including non-family members)

Surname Forename DoB SSD case number if appropriate Relationship to child Tick if also referred to SSD

Significant family members who are not members of childís household

Name Name

Relationship Relationship

Address Address

Tel. Tel.

Child/young personís religion Child/young personís ethnicity:

Caribbean n Indian n White British n White and n Chinese n

Black Caribbean

African n Pakistani n White Irish n White and n Any other n

Black African ethnic group

Any other n Bangladeshi n Any other n White and n Not given n

Black background White background Asian

Any other Asian background n Any other mixed background n

If other, please specify Childís first language Parent(s) first language

Is an interpreter or signer required? Yes n No n Has this been arranged? Yes n No n

Information on statutory status

Yes No Please give details:

Child/young person or other child(ren)/ Name Date(s)

young person(s) in family is/has on a

disability register n n

Child/young person or other child(ren)/ Name Date(s) Category

young person(s) in family is/has on a

child protection register n n

Child/young person or other family Name Date(s)

member(s) has/have been looked

after a local authority n n

Other SSD cases associated with the child/young person

Name Case No. Name Case No.

Name Case No. Name Case No.

Key agencies (please tick if currently working with the family)

G.P. n Tel. H.V. n Tel.

Nursery n Tel. E.W.O. n Tel.

School n Tel. Police n Tel.

Y.O.T. n Tel. Dentist n Tel.

Community Mental Health n Tel. Community Paediatrician n Tel.

School Nurse n Tel. Other n Tel.

Reason for referral/request for services:

Name of staff member completing this referral Signature Date

Further action: Practice note: ensure this referral is collated with previous referrals or files

Provision of information and advice n Referral to other agencies (please state which) n

Initial assessment (to be completed within 7 working days) n

No further action n

Reason for Further Action

Name of Team Manager Signature Date

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