Multi Agency Referral Form (marf)




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Multi Agency Referral Form (MARF)




This form should only be used to make a referral to Sandwell’s child protection Multi Agency Safeguarding Hub (MASH).
If a child is at imminent significant risk of harm/immediate danger, you should consider calling 999 in the first instance (for Police or an Ambulance) and contacting children’s social care by telephoning Sandwell's Contact Centre on 0121 569 3100 (out of office hours is the same number). You will also be expected to complete a MARF without delay.
If the child is in no immediate danger you must complete a MARF as soon as possible and within a maximum of 24 hours.
Send the MARF by secure email to access_team@sandwell.gcsx.gov.uk with the subject title MARF

(For those agencies who do not have secure email, please password protect the MARF before sending, and telephone Sandwell's Contact Centre to advise them of the password)


For guidance on completing the MARF please see the accompanying Sandwell MARF Guidance and Multi Agency Thresholds documents




  1. CHILD / YOUNG PERSON’S DETAILS

Family Name

     

First Name(s)

     

Date of Birth/ Estimated Due Date

   /    /   


Gender

 Male

 Female


 Unborn

Age

     

Ethnicity

If ‘Other’, please specify




     

Religion

If ‘Other’, please specify





     


First Language

     

Interpreter required?

Why/who for?



Y / N / Not Known

  


     

NHS Number

     

Address

     



Home Telephone No.

     

Mobile No.

     

GP Address/ Contact

     



Nursery/School/ Children’s Centre

Address/ Contact



     

In order to identify the correct child / young person requiring the assessment, please include a description of the child’s physical characteristics: e.g. Colour of Eyes, Hair, Skin, Approx Height/Weight and any distinguishing marks

     



Child’s Voice

(Please provide an explanation)

Is the child or young person aware of the referral? Y / N / NK

  


Have their wishes and feelings been included? Y / N / NK

  


     






  1. DETAILS OF REFERRAL

Describe the identified cause for concern - what is the impact (or potential impact) on the child/ young person?

     



On what evidence / information is your concern based?

     






  1. FAMILY CONTEXT

Outline your agency’s role / service provided to the child and or family.

Confirm how long you have been involved; include any history of concerns and when you last saw the child/ family



     

Outline your knowledge of the child’s needs and parent’s capacity to meet these. Include any family and environmental factors that impact on child’s need and parent’s capacity.

     

Please provide details, and where known contact details, of other professionals/ agencies involved with the family

     




  1. FAMILY COMPOSITION AND HOUSEHOLD MEMBERS (e.g. siblings/stepfather/carer)

Name

Gender

DOB

Relationship to subject child

School; Nursery; Children’s Centre

GP

     



M / F / NK

  


   /    /   

     

     

     

     



M / F / NK

  


   /    /   

     

     

     

     



M / F / NK

  


   /    /   

     

     

     

     



M / F / NK

  


   /    /   

     

     

     




  1. SIGNIFICANT OTHERS - NOT IN THE HOUSEHOLD

Name

Gender

Date of Birth

Relationship to subject child

Does this person hold parental responsibility?

Is this person known to pose a risk to children - PPRC?

     


M / F / NK

  


   /    /   

     

Y / N / NK

  


Y / N / NK

  


     


M / F / NK

  


   /    /   

     

Y / N / NK

  


Y / N / NK

  


     


M / F / NK

  


   /    /   

     

Y / N / NK

  


Y / N / NK

  





  1. CONSENT & CONFIDENTIALITY

Is the parent aware of the referral?

 Yes  No

Has the parent given consent to the referral being made?

 Yes  No

If the answer to either of the above is No please provide an explanation. It is essential that professionals work in partnership with families and talk to them about their concerns, unless to do so would place a child or family at immediate risk of harm

     



Have parents been advised that support may be offered from Early Help Services?

 Yes  No

If the answer to the above is yes, have parents consented to this?

 Yes  No

Is any information contained in this referral to remain confidential from the subject child and family? If so, please outline specific information to remain confidential and reasons.

NB details of referrer, if a professional person, cannot be held as confidential save in exceptional circumstances

     


Name of person completing referral

     

Relationship to child being referred

     

Date

     

Time

     

Tel No.

     

Agency

     

Address

     


Email

     

Name & contact details of person to whom feedback should be provided (if different to above)

     




July 2015




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