Waltham Forest Referral Form Child`s Details Child`s race / ethnicity

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Waltham Forest Referral Form Child`s Details Child`s race / ethnicity
Waltham Forest Referral Form
Child’s Details
First name
Surname
Age
Date of birth
Gender
Male
Female
Language spoken at home
Home address
Child’s race / ethnicity
School year
Religion
Telephone (home)
Mobile
Is this a single parent household?
Yes
No
Please identify the child’s main carer(s):
Name
Relationship to child
Name
Relationship to child
Who else is involved in the child’s upbringing, e.g. child’s father, mother’s partner?
Is an interpreter required?
If yes, please specify which language
Yes
No
Please mark X in relevant box
White
British
Irish
Other (specify):
Black or Black British
Caribbean
African
Other (specify):
Mixed
White and Caribbean
White and Black African
White and Asian
Other (specify):
Asian or Asian British
Indian
Pakistani
Bangladeshi
Chinese
Other Ethnicity
Have you told the child’s parent / carer about this programme?
Is the parent/carer aware of the ECHO project – an evaluation of Chance UK’s
service – and how they would be involved if the referral is eligible? (A parent
information leaflet is provided)
Specify:
Please outline your reasons for making this referral and give any other relevant information.
Use additional sheets or submit a separate attachment if necessary.
Referrer’s details
Name
Agency
Address
Position
For office use only
Date referral received
Meets criteria
Yes / No
Result of risk assessment
Phone
Name and address
of child’s school if
different from above
E-mail
Name of child’s class teacher if different from above
Name of social worker
E-mail
Telephone*
High
Low
Inconclusive
Score
PS
Date referrer informed of
assessment result
Date allocated to staff member
Child / family background
Is the child or family known to social care? If yes, please give details:
Child protection plan
Fostering
Children in need
Looked after children
Family support worker
Drugs and alcohol
Other
Is the child or family known to Educational Welfare?
Does the Child/Family Consultation Service know the child / family?
Is the child or family known to the probation service?
Are our mentors / staff at risk of danger or abuse from family
members or their associates? If yes please give details.
Yes
Yes
Yes
Yes
No
No
No
No
Don’t know
Don’t know
Don’t know
Don’t know
Yes
Yes
Yes
No
No
No
Don’t know
Don’t know
Don’t know
Home life
Do any members of the child’s family have a criminal history?
Do any members of the child’s family have a problem with addiction?
Do any of the child’s friends have a negative influence on him / her?
How consistent is the parent / carer’s supervision of the child?
Very poor
Poor
Below average
Average
Good
Very good
Don’t know
How stable is the child’s background / family situation?
Very poor
Poor
Below average
Average
Good
Very good
Don’t know
Please rate the child’s relationship with his or her mother
Very poor
Poor
Below average
Average
Good
Very good
Don’t know
Please rate the child’s relationship with his or her father
Very poor
Poor
Below average
Average
Good
Very good
Don’t know
School life
Does the child have attention deficit / hyperactivity disorder?
Has the child been diagnosed with autism?
Does the child have a severe learning difficulty that would prevent
him/her from having the necessary level of understanding to engage
with the programme?
Is there a CAF in place for this child?
Has the child been excluded from school?
For how many days was the child excluded in the last school year?
Does the child have special education needs? If yes, please give details
Yes
Yes
Yes
No
No
No
Don’t know
Don’t know
Don’t know
Yes
Yes
No
No
Don’t know
Don’t know
Yes
No
Don’t know
Does the child have a statement of needs?
Yes
Does the child receive free school meals due to low family income?
Yes
Please rate the parent/carer’s relationship with the school
Very poor
Poor
Below average
Average
Good
Please rate the child’s academic record
Very poor
Poor
Below average
Average
Good
Please rate the child’s school attendance record
Very poor
Poor
Below average
Average
Good
Please state the reasons for any frequent or prolonged absences from school
Truancy
Illness
Don’t know
Other (please specify below)
No
No
Don’t know
Don’t know
Very good
Don’t know
Very good
Don’t know
Very good
Don’t know
ECHO Project – an evaluation of Chance UK’s early intervention mentoring programme
Chance UK’s service is being evaluated to find out more about its impact on children’s lives. The Social Research Unit at
Dartington will run the evaluation in a project called ECHO: Evidence for Children’s Outcomes.
School staff will be asked to assist in the evaluation by giving their valuable perspective on a child’s behaviour via a
short questionnaire. Please read carefully the enclosed information sheet about the ECHO project, and then sign the
statement below if you agree to take part.
I have read the information sheet about the evaluation of Chance UK’s service and I understand that:







The information I provide will be used by the research team to contact the child’s family in order to assess their
suitability for Chance UK’s service.
I will be asked to complete the Strengths and Difficulties Questionnaire (SDQ) and this will be used to assess
the child’s eligibility for the service and to monitor changes in the child’s behaviour and emotional wellbeing.
If the child is involved in the evaluation, the research team will contact me to arrange a time for me or another
member of school staff to complete the SDQ at two follow-up time points (around nine and sixteen months
after referral) so that the research team can monitor changes in the child’s outcomes.
Completion of the questionnaires is voluntary and I can stop taking part in the project at any time.
The information I provide will be kept confidential and stored appropriately.
The information I provide will be analysed and reported at a group level where no individual or their views
could be identified.
The research project will be reviewed by an independent ethics committee.
Knowing the above, I agree to take part in this project
Signed:
Date:
Yes
No
Goodman Strengths and Difficulties Questionnaire (SDQ)
Copyright Robert Goodman 1997. Permission granted for use.
Please rate the child’s behaviour over the last six months, or over the last school year, by marking X in one box in each row below.
Not
true
Considerate of other people’s feelings
Restless, overactive, cannot stay still for long
Often complains of headaches, stomach-aches or sickness
Shares readily with other children (treats, toys, pencils etc)
Often has temper tantrums or hot tempers
Rather solitary, tends to play alone
Generally obedient, usually does what adults request
Many worries, often seems worried
Helpful if someone is hurt, upset or feeling ill
Constantly fidgeting or squirming
Has at least one good friend
Often fights with other children or bullies them
Often unhappy, down-hearted or tearful
Generally liked by other children
Easily distracted, concentration wanders
Nervous or clingy in new situations, easily loses confidence
Kind to younger children
Often lies and cheats
Picked on or bullied by other children
Often volunteers to help others (parents, teachers, other children)
Thinks things out before acting
Steals from home, school or elsewhere
Gets on better with adults than with other children
Many fears, easily scared
Sees tasks through to the end, good attention span
Name of person who completed this SDQ
Position
Child’s name
Date
Somewhat
true
Certainly
true
Office
For office use only
For office use only
Please circle your response
PP
(
)
A (5–10)
B (4)
N (0–3)
ES
(
)
A (6–10)
B (5)
N (0–4)
CP
(
)
A (4–10)
B (3)
N (0–2)
HA
(
)
A (7–10)
B (6)
N (0–5)
Total
(
)
A (16–40)
B (12–15)
N (0–11)
PS
(
B (5)
N (6–10)
)
A (0–4)
Scored by
Meets criteria
Date
Yes
No
Monitoring information entered on database by
Follow up information taken and attached here by
Notes
Please return your completed referral form to:
Chance UK
[email protected]
Senior Programme Manager – Enfield and Waltham Forest
020 7281 5858 ext. 214
07703 189 420
Charity Registration No.1046947 – Company Registration No.3057840

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