MASH Safeguarding Referral Form

Welcome to Croydon's Interagency Safeguarding Referral Form

business support

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:

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

About the Child

First name is required
Last name is required
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
Age is required
Gender is required
Ethnicity is required
Ethnicity Other details is required
Religion is required
Religion Other is required
Disability/SEN statement is required
Disability statement description is required
Interpreter Required is required
Interpreter Language description is required
School Other description is required

Enter the child's address

Contact number is required Contact number should contain 11 digits

business support

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 is required
Last name is required
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
Age is required
Gender is required
Primary care holder to child is required
Relationship to child is required
Has parental responsibility is required
Ethnicity is required
Ethnicity Other details is required
School Other description is required
Disability/SEN statement is required
Disability/SEN statement is required
NI Number is required

Enter the address

Contact number is required Contact number should contain 11 digits

Information about you - the professional completing this form

First name is required
Last name is required
Organisation is required
Job title is required
Agency email is required Agency email is not valid eg: @croydonhealth.nhs.uk or @met.police.uk
Contact number is required Contact number should contain 11 digits
Relationship to the child is required

business support

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 is required
Last name is required
Organisation Type is required
Organisation is required
Job title is required
Contact number is required Contact number should contain 11 digits
Relationship to the child is required
Their View is required
Early Help Assessment Completed is required
Lead Professional is required
Your document has been uploaded Please upload your document
Support The Family is required
Your document has been uploaded Please upload your document
Have Discussed With Mash is required
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

Your Concern is required
What prompted you is required
Anybody else present is required
Date of birth is required Expected format: dd/mm/yyyy Selected date is invalid Date is smaller than allowed
Present location is required
Child experienced is required
Last seen by the child / family is required
Is Physical Harm is required
Describe Physical Harm is required

business support

Croydon Children & Family Partnership

Section Reason for Concern continue...

Is there suspected or history of Mistreatment? Please select Yes or No in the box as appropriate

Further information is required
Further information is required
Further information is required
Further information is required
Further information is required
Further information is required
Further information is required
Further information is required
Further information is required
Further information is required
Further information is required
Further information is required
Further information is required
Right to live in UK Detail is required
'Yes' should be selected for at least one option

business support

Croydon Children & Family Partnership

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

YourInvolvementPeriod is required
ActionExpectedFromCC is required

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

Severity is required
Is Physical Harm is required
Duration is required
Is Physical Harm is required

The Child/s Voice

SpokenToChild is required
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

ConsentLevel is required
ConsentLevelDetail is required

Summary

Section 1 - About the child

{{wizardObj.model.ChildInfo.FirstName}}
{{wizardObj.model.ChildInfo.LastName}}
{{wizardObj.model.ChildInfo.Address.addressLine1}} {{wizardObj.model.ChildInfo.Address.addressLine2}} {{wizardObj.model.ChildInfo.Address.town}} {{wizardObj.model.ChildInfo.Address.postcode}}
{{wizardObj.model.ChildInfo.ContactNumber}}
{{wizardObj.model.ChildInfo.DateOfBirth}}
{{wizardObj.model.ChildInfo.Age}}
{{wizardObj.model.ChildInfo.Gender}}
{{wizardObj.model.ChildInfo.Ethnicity}}
{{wizardObj.model.ChildInfo.Ethnicity}}
{{wizardObj.model.ChildInfo.Religion}}
{{wizardObj.model.ChildInfo.ReligionOther}}
{{wizardObj.model.ChildInfo.Disabilities}}
{{wizardObj.model.ChildInfo.DisabilityDetail}}
{{wizardObj.model.ChildInfo.InterpreterRequired}}
{{wizardObj.model.ChildInfo.InterpreterLanguage}}
{{wizardObj.model.ChildInfo.School}}
{{wizardObj.model.ChildInfo.GPDetails}}
{{wizardObj.model.ChildInfo.PupilUniqueRefNo}}
{{wizardObj.model.ChildInfo.CroydonICSNo}}
{{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)

{{item.FirstName}}
{{item.LastName}}
{{item.DateOfBirth}}
{{item.Ethnicity}}
{{item.Gender}}
{{item.PrimaryCareHolder}}
{{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}}
{{item.Relationship}}
{{item.School}}
{{Item.GPDetails}}
{{item.ParentalResponsibility}}
{{item.FinancialSupport}}
{{item.EmploymentOrEarlyLearningSupport}}
{{item.NINo}}

ISection 3 - About You

{{wizardObj.model.YourInfo.FirstName}}
{{wizardObj.model.YourInfo.LastName}}
{{wizardObj.model.YourInfo.Organisation}}
{{wizardObj.model.YourInfo.JobTitle}}
{{wizardObj.model.YourInfo.Email}}
{{wizardObj.model.YourInfo.ContactNumber}}
{{wizardObj.model.YourInfo.Relationship}}
{{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.)

{{item.FirstName}}
{{item.LastName}}
{{item.OrganisationType}}
{{item.Organisation}}
{{item.Relationship}}
{{item.ContactNumber}}
{{wizardObj.model.item.Address.addressLine1}} {{wizardObj.model.item.Address.addressLine2}} {{wizardObj.model.item.Address.town}} {{wizardObj.model.item.Address.postcode}}
{{item.TheirView}}
{{item.EarlyHelpAssessmentCompleted}}
{{item.LeadProfessional}}
[Attached]
{{item.SupportTheFamily}}
[Attached]
{{item.HaveDiscussedWithMash}}
{{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

{{wizardObj.model.ReasonForConcern.WhyYouConcern}}
{{wizardObj.model.ReasonForConcern.WhatPromptedYou}}
{{wizardObj.model.ReasonForConcern.AnybodyElsePresent}}
{{wizardObj.model.ReasonForConcern.WhenHappened}}
{{wizardObj.model.ReasonForConcern.PresentLocation}}
{{wizardObj.model.ReasonForConcern.Experienced}}
{{wizardObj.model.ReasonForConcern.LastSeenByYou}}
{{wizardObj.model.ReasonForConcern.IsPhysicalHarm}}
{{wizardObj.model.ReasonForConcern.DescribePhysicalHarm}}

Is there suspected or a history of…

{{wizardObj.model.MistreatmentDetails.SexualAbuse}}
{{wizardObj.model.MistreatmentDetails.SexualAbuseDetail}}
{{wizardObj.model.MistreatmentDetails.AlcoholAbuse}}
{{wizardObj.model.MistreatmentDetails.AlcoholAbuseDetail}}
{{wizardObj.model.MistreatmentDetails.MentalIllHealth}}
{{wizardObj.model.MistreatmentDetails.MentalIllHealthDetail}}
{{wizardObj.model.MistreatmentDetails.EmotionalAbuse}}
{{wizardObj.model.MistreatmentDetails.EmotionalAbuseDetail}}
{{wizardObj.model.MistreatmentDetails.Neglect}}
{{wizardObj.model.MistreatmentDetails.NeglectDetail}}
{{wizardObj.model.MistreatmentDetails.DomesticAbuse}}
{{wizardObj.model.MistreatmentDetails.DomesticAbuseDetail}}
{{wizardObj.model.MistreatmentDetails.ChildSexualExploitation}}
{{wizardObj.model.MistreatmentDetails.ChildSexualExploitationDetail}}
{{wizardObj.model.MistreatmentDetails.Trafficking}}
{{wizardObj.model.MistreatmentDetails.TraffickingDetail}}
{{wizardObj.model.MistreatmentDetails.FGM}}
{{wizardObj.model.MistreatmentDetails.FGMDetail}}
{{wizardObj.model.MistreatmentDetails.ForcedMarriage}}
{{wizardObj.model.MistreatmentDetails.ForcedMarriageDetail}}
{{wizardObj.model.MistreatmentDetails.HonourBasedViolence}}
{{wizardObj.model.MistreatmentDetails.HonourBasedViolenceDetail}}
{{wizardObj.model.MistreatmentDetails.Extremism}}
{{wizardObj.model.MistreatmentDetails.ExtremismDetail}}
{{wizardObj.model.MistreatmentDetails.MissingFromHorS}}
{{wizardObj.model.MistreatmentDetails.MissingFromHorSDetail}}
{{wizardObj.model.MistreatmentDetails.RightToLiveInUK}}
{{wizardObj.model.MistreatmentDetails.RightToLiveInUKDetail}}
{{wizardObj.model.ActionDetails.ActionTakenByYou}}
{{wizardObj.model.ActionDetails.YourInvolvementPeriod}}
{{wizardObj.model.ActionDetails.ActionExpectedFromCC}}
{{wizardObj.model.ActionDetails.Severity}}
{{wizardObj.model.ActionDetails.Frequency}}
{{wizardObj.model.ActionDetails.Duration}}
{{wizardObj.model.ActionDetails.Stage}}
{{wizardObj.model.ConsentDetails.SpokenToChild}}
{{wizardObj.model.ConsentDetails.SpokenToChildDetail}}
{{wizardObj.model.ConsentDetails.ConsentLevel}}
{{wizardObj.model.ConsentDetails.ConsentLevelDetail}}

Section 6 - 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

{{wizardObj.model.ConsentDetails.ConsentLevel}}
{{wizardObj.model.ConsentDetails.ConsentLevelDetail}}

business support

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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