Name of Child:
Date of Birth:
School / Setting
Strengthening Families Programme 6 week course. Parents and young person attends. For
young people aged over 10 - under 14. Course run’s on a Wednesday morning’s
9.30 12.30 from Castleton Community Centre. Castleton.
Name of Mother, Father or carer who you are referring:
Contact Telephone Numbers:
Has the family consented to this request being made?
Request Made By:
Name, Agency & Contact
Name of person completing this
referral form:
Date of Request
Reason for request
*** please include as much information as possible or this will delay the referral***
Is childcare required for any other children - whilst they attend the programme
If so please complete
details for each child
Name & DOB
Name & DOB
Name & DOB
Name & DOB
Any known risk to the
practitioner visiting the
Other agencies involved with the family if known
Family member
receiving support
Worker’s name and
contact details
The information you have provided may be discussed with other relevant agencies/workers if
appropriate. This is to ensure that you receive the best service possible. We work in a team with
relevant professionals and basic information may be shared with them for their monitoring
purposes. We promise only to share minimum information necessary with relevant people. The
information you provide will be securely stored with restricted access and will be treated in
accordance with the Data Protection Act 1998. Your information will be appropriately destroyed
once the information is no longer required
Find out how we use your personal information at
Please return via email to
Or post to : Sure Start Children’s Centres Team
Floor 4 Number 1 Riverside
Smith Street, Rochdale. OL16 1XU (Tel: 0300 303 0430)
Version 7. August 2018