Fillable Hertfordshire Service Request Form Children and young people (Hertfordshire County Council)

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Hertfordshire Service Request Form Children and young people (Hertfordshire County Council)

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1
Hertfordshire
Service Request Form
Children and young people
This form should be used when a child or young person has a need which requires a response
from one agency only. For multiple needs consider a Families First Assessment.
For child protection referrals use the Hertfordshire
Child Protection Referral Form or ring 0300 123 4043
What service are
you requesting? *
Integrated Services for
Learning (ISL)
Other
Attendance 0-25 together team
Communication and Autism Targeted youth support
Educational Psychology Intensive family support teams
Physical and Sensory YC Hertfordshire
Central Attendance and
Employment Support
Young carers
Early Years SEND Don’t know
Education Support Team for
Medical Absence (ESMA)
Requests for any other team
s or
services will not be accepted by ISL
If you are requesting an ISL
service, please ensure you
complete the “ISL baseline
assessment information” form
and include within your
correspondence.
Access to Education for
Refugees and Travel
lers
Specialist Advisory Service
(5-25)
Specific Learning Difficulties
(SpLD)
What is the reason
for your request? *
What are the desired
outcomes for the
child/
young person/family? *
* Please use the space provided on page 5 of this form if you need to add further information.
2
Child / young person / unborn baby details
Forename(s):
For unborn baby insert “UBB”
Date of birth / expected delivery date:
Surname:
Gender:
Male Female Unknown
P
rimary
address:
Postcode:
Disability: No Yes
Please supply details:
Religion:
S
econdary
address:
Postcode:
Parent/carer email address*
Name, address and contact details
of health visitor/school nurse:
Postcode:
Childs first
language:
Reference number:
(e.g. NHS Number, Unique Pupil Number)
Name, address and contact details of GP:
Postcode:
Name of early years setting/school/college
and contact person:
*SCHOOLS/PARENTS & CARERS: HERTSFX - Secure File Exchange Arrangement
Hertfordshire County Council uses a web system HertSFX, to protect the data we hold and share as
a main electronic communication method.
• In order to receive information via HertSFX, children’s services will send you an ‘invitation’ so
you can register.
• Once you have completed the registration process, you will be able to login and view / download
any information sent from children’s services via HertSFX.
• By providing your email address you are agreeing to join the HertSFX system & agree to contact
HCC should your email address change.
Once you have completed the registration process, you will be able to login and view/download
any information sent from Children’s Services via HertSFX.
Other
3
Parent/carer details
Please give names of child’s primary carer(s) and their relationship to the child/young person.
Full name Address
(if different from the child)
Date of birth
(DOB)
Gender Parental
Responsibility
Postcode:
Tel:
M
F
Yes
No
Unknown
Postcode:
Tel:
M
F
Yes
No
Unknown
Do the parent/carer(s) have a disability?
No Yes please give details
First Language:
Is an interpreter /signer required?
Yes No
Family composition/significant others
Full name Address, Postcode, and Tel DOB if
known
Relationship to
children named
overleaf
Gender
M
F
M
F
M
F
M
F
M
F
M
F
4
What other services are involved with this child/young person/family
e.g. adult services, Child and Adolescent Mental Health Services
(CAMHS) etc, if known.
Name of Professional and
Organisation
Address, Postcode, and Tel
Brief description of
work undertaken or
ongoing support
5
Additional information - Please use this box to provide additional relevant information to
support your request when contacting Children's Services.
Name of person making/completing this Service
Request Form (full name and agency/service
must be entered)
Contact Details
(include email address and contact number)
Date form completed and sent
6
Data Privacy and Information Sharing Statement
I confirm that following discussion with school/setting staff, I agree to the involvement of Children’s
Services.
I have had the reasons for this service request explained to me, I understand the reasons for the
request and understand that my information will be shared with Children’s Services as part of this
request. I agree to the request and give consent for Children’s Services to work with my child (or
me as the named young person).
I understand that working with my child (or me) will necessitate the sharing of information between
relevant services, in the interests of providing a service to me or my child. I understand that the
information contained within this form will be recorded on a Hertfordshire County Council case
management system and other services may be able to see the content on this form. Hertfordshire
County Council is the Data Controller for this information and its lawful basis for processing is to
fulfil its duties in respect of special educational needs provision (public task).
Information on you or your child/young person will be held until 35 years after the date of birth.
Full information on your rights in respect of personal data held about you can be found at
https://www.hertfordshire.gov.uk/about-the-council/legal/privacy-policy/privacy-policy.aspx
Please tick the relevant services you do not wish information to be shared with, however please
note there may be circumstances where we have to share your details without your consent e.g. if
we believe it is the best interests of a child:
Social Care
National Health Services partners (Paediatricians, Speech & Language
Therapists, CAMHS etc)
Child/young person Parent/carer
Signature: Signature:
Name: Name:
Date: Date:
Note: If the young person is the age of 16 or over and has mental capacity, they must provide a
signature (and a parent signature is not required).
7
If the child is under the age of
16 and has not provided a
signature, have you sought
verbal consent?
Yes No
If no, please state why:
8
Service / Area / District Email
0-25 Together team
protectedreferrals.cs@hertfordshire.gov.uk
Targeted Youth Support
Intensive Family Support Teams
Young Carers
YC Hertfordshire
0300 123 7538 or email –
ychreferral@hertfordshire.gov.uk
If you are requesting an ISL service, please ensure you complete the “ISL baseline
assessment information” form and include within your correspondence.
North Herts and Stevenage NHSTEV.ISLTEAM@hertfordshire.gov.uk
East Herts, Broxbourne, Welwyn & Hatfield EHBROX.ISLTEAM@hertfordshire.gov.uk
St Albans and Dacorum STADAC.ISLTEAM@hertfordshire.gov.uk
Watford, Three Rivers & Hertsmere WAT3RIV.ISLTEAM@hertfordshire.gov.uk
If you would like to speak to someone please telephone the Customer Service Centre on 0300
123 4043 and ask to speak to someone in the relevant team for the area you live in.
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Completed 19 January 2021

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