October 2014
Page 1
1. CONSENT (Please note that consent should be sought from the parent/carer unless obtaining this consent will place the child
at further risk of significant harmobtaining consent should not delay a referral being made)
Has consent been sought from PARENTS/CARERS
before making this referral?
No
Yes
If consent has not been
obtained, please give reason.
2. DETAILS OF PRACTITIONER MAKING THIS REFERRAL
Name of Referrer:
Job title:
Agency:
Address:
Tel/Mobile:
Email:
Date:
Details of Social
Worker taking
referral
3. CHILD/YOUNG PERSON DETAILS
Last Name
First Name
DOB/EDD
Age
M/F
Ethnicity *
Preferred
Language
Address(es):
Tel/ Mobile:
Email:
4. CHILD/YOUNG PERSON’S MAIN CARERS
Carer Last Name
Carer First Name
DOB
M/F
Ethnicity
Relationship to
child
Parental
Responsibi
lity
Give carer address(es) here
if different from the child’s:
Tel/Mobile:
Email:
5. OTHER HOUSEHOLD MEMBERS or SIGNIFICANT PEOPLE IN THE CHILD/YOUNG PERSON’S LIFE (where
known)
Last Name
First Name
DOB/EDD
Age
M/F
Ethnicity
Relationship to
child
INTER-AGENCY REFERRAL FORM
October 2014
Page 2
Are there any communication/
interpreting needs for the child and/or
family?
Does the child and/or family have a
disability or special needs?
6. REASON FOR REFERRAL
Why are you contacting us
/ What are you worried
about?
Risks
Please tell us your opinion of the level of risk to the child and detail
explicitly your reasoning for this. [to tick boxes double click on box and select
checked]
Low Medium High
What type of harm the child
is suffering or likely to be
suffering and any known
history of harm.
If any disclosures made
include who by and when
Parents’ capacity to meet
child’s needs adequately
Framework for Assessment
October 2014
Page 3
How in your opinion this
impacts on the child’s
health and/or development
/ analysis of risk.
7. HAS THERE BEEN PREVIOUS STATUTORY OR SPECIALIST INVOLVEMENT?
[to tick boxes double click on box and select checked]
Children’s Social Care
No
Yes
Not Known
Child and Adolescent Mental Health Service CAMHS
No
Yes
Not Known
Special Educational Needs or Disability
No
Yes
Not Known
Borough School Attendance Service / Education Welfare Service
No
Yes
Not Known
Specialist Health
No
Yes
Not Known
Adult Services (Mental Health /Drug or Alcohol Abuse /Disability /DV /
Housing)
No
Yes
Not Known
Youth Justice Service
No
Yes
Not Known
Police/Probation/
No
Yes
Not Known
New to Borough
No
Yes
Not Known
Other
No
Yes
Not Known
8. HAS AN EARLY HELP ASSESSMENT e.g. COMMON ASSESSMENT
FRAMEWORK (CAF) BEEN COMPLETED?
No
Yes
If yes, please attach (if
available)
9. OTHER PROFESSIONALS INVOLVED (TO INCLUDE GP AND SCHOOL DETAILS)
Name / Title
Team/Agency
[school / GP/ HV etc]
Unique
Pupil No.
Address
Telephone/Mobile /
Email
COPY THIS FORM SECURELY TO MASH EMAIL/FAX OPTIONS AS FOLLOWS:
Before contacting the Multi Agency Safeguarding Hub (MASH) you need to consider whether the child or young
person's needs can be met by services from within your own agency, or by other professionals already involved
with the family (refer to the Royal Greenwich Preventions Directory). If you are not sure about the needs of the child
or whether you should make a referral you can discuss with your Safeguarding Lead and if you are still not sure you
can call the MASH Consultation Line on 020 8921 2267 to discuss the case with professionals in the MASH.
We know that it is sometimes difficult to decide the appropriate point of intervention. To help you to determine
levels of need when making your own assessment, please refer to the threshold document.
If you are making a referral please contact:
Tel: 020 8921 3172 Fax: 020 8921 3180
Email: MASH-referrals@royalgreenwich.gov.uk
Royal Borough of Greenwich MASH, 1st Floor The Woolwich Centre, 35 Wellington Street, London SE18 6HQ
OUT OF HOURS: TEL CONTACT: 020 8854 8888
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