About this referral

Eligibility: We can only accept referrals for families living in BB1, BB2 or BB3 or residents within Blackburn with Darwen.

I confirm the family lives in BB1, BB2, BB3 or within Blackburn with Darwen.

All referrals must be made with the consent of the individual. Have you discussed this referral with the individual prior to completing this form?

I confirm the client has given consent to this referral.

About the referrer

Please list any current services/professionals involved with the family (include contact details if known)

Parent / Carer details

Please complete as much as possible.

Mother

Email

Father

Email

Significant other

Email

Household and address

How many adults are in the household?*

Family address*

Family postcode*

Equalities monitoring (optional)

Child / children details

Please enter the child/children details in age order.

Child 1

School / Nursery

Child 2

School / Nursery

Reason for referral

Lone parentMental health concernsPeri/Post natal depressionPast/Current substance misusePast/Current domestic abuseDebt/Financial difficultiesChild disability/health needsTeenage pregnancy (19 and under)Other

Children’s needs

Managing children’s behaviourLearning and developmentChild’s physical wellbeingChild’s emotional wellbeingChild’s social confidenceAdditional needs / disabilitySchool attendance / engagement concernsOther

Please explain the child/children’s needs*

Parent needs

Parent physical wellbeingParent mental wellbeingParental isolationSelf-esteem and confidenceParent’s learning needsRelationship / co-parenting difficultiesOther

Family management

Managing household budgetDay-to-day running of the homeManaging stress in the familyMultiple birth / multiple children under 5Using services to promote learning

Please tell us if the following apply:

CAMHS / Social work involvementChild subject to Assessment of NeedChild in Need / CP PlanPets in householdSmokers

Other relevant background information

Pets

Are there any pets?

NoYes

If yes, please provide details

Safeguarding / placement considerations

Any other comments?

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