Referral Form

Referral for Family Support

Inter-Agency / Self Expression of Interest Form

Dry Arch Family Support HUB – Privacy Notice and Consent

To allow us to register families with Dry Arch Family Support HUB and to ensure that they receive relevant information and services, we will need to collect some information. This information will be used to enable the delivery of services and may require information being passed to other service providers who deliver services on our behalf.

We may also be required to provide our funders with anonymised information about our projects from time to time so that they can see how well we are doing and to improve the services registered families receive.

The information provided to us will be held on a secure database and only people that need to view it will be able to access it. At any time, an individual can ask to see the information held about them, and if circumstances change, such as home address, we will ask that you let us know so that the information we hold is up to date. We will not release the information provided to us for any purpose, other than for the purposes already described, without seeking consent to do so, unless we are obliged to do so by law.

By law, if we have a child protection concern in relation to a child and we need to make a referral to Social Services, we will give more specific information in relation to the family. Parents will always be informed in advance unless by doing so the child may be put at greater risk.

We will communicate with you via post, email, phone, text, and social media to keep you up to date with Dry Arch Family Support HUB services.

Please insert today's date to continue completing the referral form.

YYYY

2. Family Name
(Surname): *

3. Parent / Carer 1
Full Name *

4. Parent / Carer 1
Date of Birth: *

YYYY

5. Parent / Carer 2
Full Name:

6. Parent / Carer 2
Date of Birth:

YYYY

7. Antenatal *

Yes

8. If antenatal, what is the baby's due date?

YYYY

9. Child 1

Full Name
(Child being referred to organisation - if antenatal, please use "Baby") *

10. Child 1 Date of Birth
(Child being referred to organisation - if antenatal please use expected due date): *

YYYY

11. What nursery / school does this child attend? If antenatal, please write "N/A" *

12. What year of nursery / school is the child in? If antenatal / pre nursery age, please write "N/A" *

13. Child 2

Full Name:

14. Child 2 Date of Birth:

YYYY

15. What nursery / school does this child attend? If antenatal, please write "N/A

16. What year of nursery / school is the child in? If antenatal / pre nursery age, please write "N/A"

17. Child 3

Full Name

18. Child 3 Date of Birth

YYYY

19. What nursery / school does this child attend? If antenatal, please write "N/A

20. What year of nursery / school is the child in? If antenatal / pre nursery age, please write "N/A"

21. Family Home Address: *

22. Postcode *

23. Parent / Carer 1 Contact Number *

24. Parent / Carer 2 Contact Number

25. Parent / Carer 1 Email Address *

26. Parent / Carer 2 Email Address

27. Referred By:
(Name of Person making the referral) *

28. Role of Referee
(e.g Parent / Job Title) *

29. Referrer's Organisation
(If you are a parent please use N/A) *

30. Referrer's Email *

31. Referrer's Contact Number *

32. Informed consent received for referral to Dry Arch is ESSENTIAL - please confirm that consent has been received to make this referral:
(Please note: Parental consent needs to be sought for any young person under 18) *

Yes - Consent Received

No - Consent Not Received

33. Please reflect on the needs of the family below, so we can assure the best outcome. *

34. Please include details of other professionals involved and previous supports given. *

35. Please indicate any known disabilities within the family (so reasonable adjustments can be made where necessary)

36. Please provide details of what your ongoing role with this family will be: *

37.

DECLARATION

I have read and understood the information above regarding how information will be used, stored, and shared by Dry Arch Family Support HUB. I give permission for this information to be held securely and processed in line with the General Data Protection Regulation (GDPR) and the Data Protection Act 2018, for the purposes described.

I also understand that if any of the information provided changes (for example, contact details or home address), I am responsible for informing Dry Arch Family Support HUB staff so that information can be kept accurate and up to date.

38. Signed

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