Limetree Referral Form - Childhood Matters

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How We Help
About
Our Services
Crèche & Preschool
Find What You Need
Resources

Careers Make a Referral

Limetree Referral Form

1. Referral Details

Family Name *

Social Work Department

Date of Referral *

Type of service required *

Level of need *

If the Child/Children are in Care Placements, Hardiker level 4 must be selected

2. Referrer Details

Title *

Referrer Name *

Organisation Name/Social Work Department

Phone Number

Email *

Social Work Team Lead *

Name & Contact Number

Duration *

How long has the referring organisation been working with the family

3. Family Details

Are the family aware of this referral and open to engaging with the Lime Tree team *

If yes, in what capacity *

Parent/Guardian 1

Name *

Location

Address or town

Mobile Phone

Parent/Guardian 2

Name

Location

Address or town

Mobile Phone

4. Children's Details

How many children in the family are open to social work department? *

Child 1

Name *

Date of Birth *

School address

Class Level

Additional needs

Care Status

Child 2 (if applicable)

Name

Date of Birth

School address

Class Level

Additional needs

Care Status

Child 3 (if applicable)

Name

Date of Birth

School address

Class Level

Additional needs

Care Status

If there are more than 3 children please specify:

Additional Children details

Optional: upload a document with details of any further children. PDF, Word, JPG or PNG, max 10 MB.

5. Family Support & Presenting Challenges

Have the above named family been in receipt of other family support services currently or in the past *

If yes, please specify

Presenting Challenges for Parent/Guardian/Family: *

Please tick all that apply:

Domestic Violence Homeless Parenting Skills Behaviour Management Social Isolation Substance Abuse Mental Health Criminal Activity

If yes to any of the above, please give further details: *

Presenting Challenges for Children/Young person: *

Please tick all that apply:

School Refusal Self harming behaviour Suicide Ideation Low mood / Anxiety Substance Abuse Criminal Activity Physical aggression

If yes to any of the above, please give further details: *

Is the Child/Children active on CPNS? *

Is the Child/Children under a Care Order? *

6. Further Information

What are Social Work worried about with the family?

What is working well with the family?

What needs to happen?

Access Arrangements

Please provide information regarding other support services currently engaged with the child, family or parent

Are there any known issues or established risks to staff safety and wellbeing that you would like Lime Tree to be aware of?

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