Professional Referral Guidelines for Home-Start Blackburn & Darwen

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

Put the condition for consent here. 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?

About the referrer

Your name*

Job title*

Date*

Referrer’s email address*

Referrer’s organisation*

Your contact number*

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

Parent / Carer details

Please complete as much as possible. If a parent/carer is not involved, leave that section blank.

Mother

Name

Date of birth

Phone number

Father

Name

Date of birth

Phone number

Significant other

Name

Date of birth

Phone number

Household and address

Equalities monitoring (optional)

Sexual orientation

Parent’s ethnic background

Child / children details

Please enter the name(s) and date(s) of birth for the child/children. List in age order with the eldest child first.

Child 1

Child 1 name*

Date of birth*

Ethnic background*

Child’s gender*

Child 2

Child 2 name

Date of birth

Ethnic background

Child’s gender

Child 3

Child 3 name

Date of birth

Ethnic background

Child’s gender

Child 4

Child 4 name

Date of birth

Ethnic background

Child’s gender

Please list the details of any other children in the family (include school/nursery if relevant)

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 (please describe)

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)

Parent needs

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

Family management

Managing household budgetDay-to-day running of the home (routines/meal/bedtimes)Managing stress in the familyMultiple birth / multiple children under 5Using services to promote learning

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

Other relevant background information

Pets

Safeguarding / placement considerations

Are there any safeguarding, safety, or communication considerations we should be aware of when matching a volunteer?

Professional Referral Guidelines for Home-Start Blackburn & Darwen

Professional Referral – Home-Start Blackburn & Darwen

Who Can Refer?

Before You Start

Professional Referral Form

About this referral

About the referrer

Parent / Carer details

Mother

Father

Significant other

Household and address

Equalities monitoring (optional)

Child / children details

Child 1

Child 2

Child 3

Child 4

Reason for referral

Children’s needs

Parent needs

Family management

Other relevant background information

Pets

Safeguarding / placement considerations

Any other comments?

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