MASH Safeguarding Referral Form

Welcome to Croydon's Interagency Safeguarding Referral Form

This form is only for professionals. If you are a member of the public please call 0208 726 6400.

Please note: completing this form will take several minutes. You need to ensure you have the child and families details to hand before you start.

Please ensure you complete all the required fields and press SUBMIT once the form is complete. Once the form has been submitted you will receive a thank you message confirming we have received your referral.

If you are a professional concerned about a child's immediate safety, please call 0208 726 6400

Please Note:

This form cannot be saved and needs to be completed in one session. This form takes approximately 10-15 minutes to complete.
All the details would be lost if the session is left idle for more than 15 minutes.

About the Child

First name

First name is required

Last name

Last name is required

Date of birth/Delivery date

Date of birth is required Expected format: dd/mm/yyyy Selected date is invalid Date is smaller than allowed Age should be less than 21 years

If DoB Unknown, please estimate the child's Age

Age is required

Gender

Gender is required

Ethnicity

Ethnicity is required

If Other selected in Ethnicity, please state here

Ethnicity Other details is required

Religion

Religion is required

If Other selected in Religion, please state here

Religion Other is required

Disability/SEN statement

Disability/SEN statement is required

Disability/SEN statement description for the condition or need

Disability statement description is required

Is an Interpreter Required?

Interpreter Required is required

If an Interpreter required yes, Please state which language(including sign language)

Interpreter Language description is required

School

If school have selected other, please state here

School Other description is required

Pupil unique ref no.

NHS no.

Enter the child's address

Contact number

Contact number is required Contact number should contain 11 digits

Croydon Children & Family Partnership

Details about the family (Parents / Carer / Guardians / Siblings / Significant others)

The parents/carers/household members (where Y/N please select)

#	First Name	Last Name	Relationship
{{$index + 1}}	{{item.FirstName}}	{{item.LastName}}	{{item.Relationship}}

First name

First name is required

Last name

Last name is required

Date of birth

Date of birth is required Expected format: dd/mm/yyyy Selected date is invalid Date is smaller than allowed Age should be less than 21 years

If DoB Unknown, please estimate the Age

Age is required

Gender

Gender is required

Are you primary care holder?

Primary care holder to child is required

Relationship to child

Relationship to child is required

Has parental responsibility?

Has parental responsibility is required

Ethnicity

Ethnicity is required

If Other selected in Ethnicity, please state here

Ethnicity Other details is required

School

If school have selected other, please state here

School Other description is required

Does the member need support with Financial Stability?

Disability/SEN statement is required

Does the member needs funding support for an Early Learning Place or support relating to employment help

Disability/SEN statement is required

NI Number

NI Number is required

Enter the address

Please tick if the same address as the child

Contact number

Contact number is required Contact number should contain 11 digits

Information about you - the professional completing this form

First name

First name is required

Last name

Last name is required

Name of Organisation

Organisation is required

Job title

Job title is required

Email Address

Agency email is required Agency email is not valid eg: @croydonhealth.nhs.uk or @met.police.uk

Contact number

Contact number is required Contact number should contain 11 digits

Relationship to the child/Your agency's Role or Service provided

Relationship to the child is required

Croydon Children & Family Partnership

Details of Professionals involved with Child or Family

Details of Professionals involved with Child or Family (including GP, School, Health, Worker/Family Worker, etc.)

#	Name	Organisation Name	Organisation	Relationship
{{$index + 1}}	{{item.FirstName + " " + item.LastName}}	{{item.Organisation}}	{{item.OrganisationType}}	{{item.Relationship}}

First name

First name is required

Last name

Last name is required

Organisation Type

Organisation Type is required

Name of Organisation

Organisation is required

Job title

Job title is required

Contact number

Contact number is required Contact number should contain 11 digits

Relationship to child

Relationship to the child is required

What is their view?

Their View is required

Has as Early help assessment already been completed?

Early Help Assessment Completed is required

If yes, please name the Lead Professional

Lead Professional is required

If yes, please attach Early Help Assessment

Upload

Your document has been uploaded Please upload your document

If No, what has been done to support the family already?

Support The Family is required

If No, please attach support plan/professional summary

Upload

Your document has been uploaded Please upload your document

Have you discussed this already e.g. with a MASH Officer or Early Help?

Have Discussed With Mash is required

If yes, who did you speak to?

Who did you speak to is required

Reason for Concern

Reason for Concern(if your concern is about a vulnerable adult/carer we still need you to complete this section) or any other factors to take into consideration

Why are you concerned about the child?

Your Concern is required

What has prompted you to make this referral?

What prompted you is required

Was anybody else present?

Anybody else present is required

When did this happen?

Date of birth is required Expected format: dd/mm/yyyy Selected date is invalid Date is smaller than allowed

Where is the child & who are they with right now?

Present location is required

What has the child said or experienced?

Child experienced is required

When did you last see the child/ family?

Last seen by the child / family is required

Is there an indication of physical harm to the child

Is Physical Harm is required

If yes, please describe

Describe Physical Harm is required

Croydon Children & Family Partnership

Reason for concern, is there suspected or a history of…

What action have you/your agency taken to address this specific concern?

Please confirm how long you have been involved; including any historical concerns and actions taken

YourInvolvementPeriod is required

What actions would you like to see from Croydon Council?

ActionExpectedFromCC is required

Using your professional knowledge, please rate the level of risk involved:

Severity, if known

Severity is required

Frequency, if known

Is Physical Harm is required

Duration, if known

Duration is required

Overall Stage (Croydon Pathways), if known

Is Physical Harm is required

The Child/s Voice

I have spoken to the child about my concern and they are aware of this referral

SpokenToChild is required

Child viewpoint on the situation or The reason not spoken to the child

SpokenToChildDetail is required

Section Parent or Carer Consent

Getting parental consent has a significant impact on our ability to respond, particularly if we would like to be able to offer the family Early Help;
- As a referrer working with the child or family, it is your responsibility to speak with the Parent/s or Carer/s about your concerns.
- Specifically we need you to seek consent from parents or carers when making a referral (where this does not put the child at risk of harm).
- If you are unable to obtain consent you must explain why this is not possible.

A) I have spoken to the child's parents or carers to discuss my concerns and they are aware that I am making a referral but have not given their consent
B) I have spoken to the child's parents or carers and they have given me consent to make this referral
C) I have not spoken to the child's parent or carers and I have provided an explanation below as to why this has not been possible

What level of consent have you obtained?

ConsentLevel is required

The reason I have not spoken to the child's parent or carers/ have not gained consent is: *

ConsentLevelDetail is required

Summary

Section 1 - About the child

First Name: {{wizardObj.model.ChildInfo.FirstName}}

Last Name: {{wizardObj.model.ChildInfo.LastName}}

Address: {{wizardObj.model.ChildInfo.Address.addressLine1}} {{wizardObj.model.ChildInfo.Address.addressLine2}} {{wizardObj.model.ChildInfo.Address.town}} {{wizardObj.model.ChildInfo.Address.postcode}}

Telephone Number: {{wizardObj.model.ChildInfo.ContactNumber}}

Date Of Birth or Expected Delivery Date: {{wizardObj.model.ChildInfo.DateOfBirth}}

If Unknown, please Estimate the child's Age: {{wizardObj.model.ChildInfo.Age}}

Gender: {{wizardObj.model.ChildInfo.Gender}}

Ethnicity: {{wizardObj.model.ChildInfo.Ethnicity}}

If Other, Please state here: {{wizardObj.model.ChildInfo.Ethnicity}}

Religion: {{wizardObj.model.ChildInfo.Religion}}

If Other, Please state here: {{wizardObj.model.ChildInfo.ReligionOther}}

Disabilities: {{wizardObj.model.ChildInfo.Disabilities}}

If Yes, please state: {{wizardObj.model.ChildInfo.DisabilityDetail}}

Is an Interpreter Required: {{wizardObj.model.ChildInfo.InterpreterRequired}}

If yes, please state which language(includeing sign language): {{wizardObj.model.ChildInfo.InterpreterLanguage}}

School: {{wizardObj.model.ChildInfo.School}}

GP Details: {{wizardObj.model.ChildInfo.GPDetails}}

Unique Pupil No(UPN): {{wizardObj.model.ChildInfo.PupilUniqueRefNo}}

Croydon ICS No: {{wizardObj.model.ChildInfo.CroydonICSNo}}

NHS Number: {{wizardObj.model.ChildInfo.NHSNo}}

Section 2 - Details of the family - Father/Mother/other siblings or family members and/or significant others/adults (including perpetrator if applicable)

First name: {{item.FirstName}}

Last name: {{item.LastName}}

DoB/set.DoB/Age: {{item.DateOfBirth}}

Ethnicity: {{item.Ethnicity}}

Gender: {{item.Gender}}

Primary Care Holder: {{item.PrimaryCareHolder}}

Address and Telephone No: {{wizardObj.model.item.Address.ContactNumber}} {{wizardObj.model.item.Address.addressLine1}} {{wizardObj.model.item.Address.addressLine2}} {{wizardObj.model.item.Address.town}} {{wizardObj.model.item.Address.postcode}}

Relationship to child: {{item.Relationship}}

School /or nursery: {{item.School}}

GP {{Item.GPDetails}}

Has parental responsibility? {{item.ParentalResponsibility}}

Does the family need support with Financial Stability?: {{item.FinancialSupport}}

Does the family needs funding support for an Early Learning Place or support relating to employment help {{item.EmploymentOrEarlyLearningSupport}}

If yes, please provide the parent/carer NI number if available: {{item.NINo}}

ISection 3 - About You

First Name: {{wizardObj.model.YourInfo.FirstName}}

Last Name: {{wizardObj.model.YourInfo.LastName}}

Name of Organisation: {{wizardObj.model.YourInfo.Organisation}}

Job title: {{wizardObj.model.YourInfo.JobTitle}}

Email: {{wizardObj.model.YourInfo.Email}}

Telephone number: {{wizardObj.model.YourInfo.ContactNumber}}

Relationship to the Child/Your agency's Role or Service Provided: {{wizardObj.model.YourInfo.Relationship}}

Address: {{wizardObj.model.YourInfo.Address.addressLine1}} {{wizardObj.model.YourInfo.Address.addressLine2}} {{wizardObj.model.YourInfo.Address.town}} {{wizardObj.model.YourInfo.Address.postcode}}

Section 4 - Details of Professionals involved with the Child or Family (including GP, School, Health, Worker/Family Worker, etc.)

First name: {{item.FirstName}}

Last name: {{item.LastName}}

Organisation: {{item.OrganisationType}}

Organisation Name: {{item.Organisation}}

Relationship to Child: {{item.Relationship}}

ContactNumber: {{item.ContactNumber}}

Address: {{wizardObj.model.item.Address.addressLine1}} {{wizardObj.model.item.Address.addressLine2}} {{wizardObj.model.item.Address.town}} {{wizardObj.model.item.Address.postcode}}

What is their view? {{item.TheirView}}

Has an early help assessment already been completed? {{item.EarlyHelpAssessmentCompleted}}

If yes, please name the lead professional: {{item.LeadProfessional}}

Document: [Attached]

If no, what has been done to support the family already? {{item.SupportTheFamily}}

Document: [Attached]

Have you discussed this already e.g. with a MASH Officer or Early Help?: {{item.HaveDiscussedWithMash}}

If yes, who did you speak to? {{item.MashOfficer}}

Section 5 - Reason for Concern (if your concern is about a vulnerable adult/carer we still need you to complete this section) or any other factors to take into consideration

Why are you concerned about the child? {{wizardObj.model.ReasonForConcern.WhyYouConcern}}

What has prompted you to make this referral? {{wizardObj.model.ReasonForConcern.WhatPromptedYou}}

Was anybody else present? {{wizardObj.model.ReasonForConcern.AnybodyElsePresent}}

When did this happen? {{wizardObj.model.ReasonForConcern.WhenHappened}}

Where is the child & who are they with right now? {{wizardObj.model.ReasonForConcern.PresentLocation}}

What has the child said or experienced? {{wizardObj.model.ReasonForConcern.Experienced}}

When did you last see the child/family? {{wizardObj.model.ReasonForConcern.LastSeenByYou}}

Is there an indication of physical harm to the child? {{wizardObj.model.ReasonForConcern.IsPhysicalHarm}}

If yes, please describe {{wizardObj.model.ReasonForConcern.DescribePhysicalHarm}}

Is there suspected or a history of…

Sexual Abuse? {{wizardObj.model.MistreatmentDetails.SexualAbuse}}

Please Describe in Further Detail…: {{wizardObj.model.MistreatmentDetails.SexualAbuseDetail}}

Alcohol or Substance abuse? {{wizardObj.model.MistreatmentDetails.AlcoholAbuse}}

Please Describe in Further Detail…: {{wizardObj.model.MistreatmentDetails.AlcoholAbuseDetail}}

Mental ill health? {{wizardObj.model.MistreatmentDetails.MentalIllHealth}}

Please Describe in Further Detail…: {{wizardObj.model.MistreatmentDetails.MentalIllHealthDetail}}

Emotional abuse or self harm? {{wizardObj.model.MistreatmentDetails.EmotionalAbuse}}

Please Describe in Further Detail…: {{wizardObj.model.MistreatmentDetails.EmotionalAbuseDetail}}

Neglect? {{wizardObj.model.MistreatmentDetails.Neglect}}

Please Describe in Further Detail…: {{wizardObj.model.MistreatmentDetails.NeglectDetail}}

Domestic Abuse? {{wizardObj.model.MistreatmentDetails.DomesticAbuse}}

Please Describe in Further Detail…: {{wizardObj.model.MistreatmentDetails.DomesticAbuseDetail}}

Child Sexual Exploitation? {{wizardObj.model.MistreatmentDetails.ChildSexualExploitation}}

Please Describe in Further Detail…: {{wizardObj.model.MistreatmentDetails.ChildSexualExploitationDetail}}

Trafficking? {{wizardObj.model.MistreatmentDetails.Trafficking}}

Please Describe in Further Detail…: {{wizardObj.model.MistreatmentDetails.TraffickingDetail}}

Female Genital Mutilation (FGM)? {{wizardObj.model.MistreatmentDetails.FGM}}

Please Describe in Further Detail…: {{wizardObj.model.MistreatmentDetails.FGMDetail}}

Forced Marriage? {{wizardObj.model.MistreatmentDetails.ForcedMarriage}}

Please Describe in Further Detail…: {{wizardObj.model.MistreatmentDetails.ForcedMarriageDetail}}

Honour based violence? {{wizardObj.model.MistreatmentDetails.HonourBasedViolence}}

Please Describe in Further Detail…: {{wizardObj.model.MistreatmentDetails.HonourBasedViolenceDetail}}

Extremism? {{wizardObj.model.MistreatmentDetails.Extremism}}

Please Describe in Further Detail…: {{wizardObj.model.MistreatmentDetails.ExtremismDetail}}

Is the child missing from home or school? {{wizardObj.model.MistreatmentDetails.MissingFromHorS}}

Please Describe in Further Detail…: {{wizardObj.model.MistreatmentDetails.MissingFromHorSDetail}}

Does the child of the family have a legal right to be living in the UK? {{wizardObj.model.MistreatmentDetails.RightToLiveInUK}}

Please Describe in Further Detail…: {{wizardObj.model.MistreatmentDetails.RightToLiveInUKDetail}}

What action have you/your agency taken to address this specific concern? {{wizardObj.model.ActionDetails.ActionTakenByYou}}

Please confirm how long you have been involved; including any historical concerns and actions taken {{wizardObj.model.ActionDetails.YourInvolvementPeriod}}

What actions would you like to see from Croydon Council? {{wizardObj.model.ActionDetails.ActionExpectedFromCC}}

If known, Severity: {{wizardObj.model.ActionDetails.Severity}}

If known, frequency: {{wizardObj.model.ActionDetails.Frequency}}

If known, duration: {{wizardObj.model.ActionDetails.Duration}}

If known, overall Stage:(Croydon Pathways) {{wizardObj.model.ActionDetails.Stage}}

I have spoken to the child about my concern and they are aware of this referral {{wizardObj.model.ConsentDetails.SpokenToChild}}

Child viewpoint on the situation or The reason not spoken to the child: {{wizardObj.model.ConsentDetails.SpokenToChildDetail}}

If known, overall Stage:(Croydon Pathways) {{wizardObj.model.ConsentDetails.ConsentLevel}}

If known, overall Stage:(Croydon Pathways) {{wizardObj.model.ConsentDetails.ConsentLevelDetail}}

Section 6 - Parent or Carer Consent

What level of consent have you obtained? Choose one statement which best matches your situation {{wizardObj.model.ConsentDetails.ConsentLevel}}

The reason I have not spoken to the child's parent or carers/ have not gained consent is: {{wizardObj.model.ConsentDetails.ConsentLevelDetail}}

Croydon Children & Family Partnership

Croydon's Interagency Safeguarding Referral Form

Thank you for submitting a Safeguarding Referral to Croydon’s MASH.

We will make a decision in relation to the status of this referral within one working day. You will be notified of our decision at that point using the email address you have provided.

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