Lamplight API response

Child personal details:

Client location - please note we are currently only accepting referrals from Reading, Wokingham, West Berkshire, Oxford City, Vale of the White Horse and South Oxfordshire *

Is this person an adult or a child? *

Date of birth *

Gender identity: how does this person describe themselves? *

Gender identity: is this person's gender identity the same as the gender they were given at birth? *

Preferred pronouns *

Does the individual have a disability? *

Details of disability (if applicable)

Any special needs? *

Mental Health

Physical Health

Learning difficulties

Sensory needs

Behavioural issues

None

Unknown

Details of special needs (if applicable)

Ethnicity *

Child safeguarding questions:

Is there Child Services involvement with this child? *

If there is Child Services involvement, please provide a name and contact details for the primary contact and give details of the involvement

Is there police involvement with this child? *

If there is Police involvement, please provide details

Is the child on a Child Protection (CP) or Child In Need (CIN) plan? *

Please give details about any safety concerns BB4K needs to be aware of when conducting a home visit

Any other safeguarding information relevant to this referral?

Child medical information:

Any allergies? *

Any regular medication? *

Will this child have any medicines or tablets with them? *

Any other medical conditions which may affect normal activity? *

Additional medical information - if you have answered yes to any of the above, please provide details here

Child referral questions:

School details - please provide the name of the child's school and the name and role of a contact at the school *

What is the main concern regarding this child? *

What does the child want to get out of this group? / What do you hope the child will get from the group? *

Please give details of perpetrator and any contact with this child - how long has this been the case? *

How is this child’s behaviour being managed at the moment? What strategies have been agreed and what works well? *

How does this child relate in a group setting? ie class, playground *

What other agencies are involved with the family? *

Has other domestic abuse work being undertaken with the family? Eg Freedom programme / Recovery Toolkit *

Do you consider the child able to cope with and benefit from working in a group? *

Is the child’s level of spoken English adequate for working in such a group? If no, please give details *

Any other information relevant to this referral?

BB4K child referral form

Other information

Child personal details:

Child safeguarding questions:

Child medical information:

Child referral questions:

IMPORTANT: after submitting this form, please return to your email to ensure you have completed referral forms for the parent/carer and for each child being referred