Transcription of Single Contact Form Exemplar/Guide - Cumbria LSCB
1 We are working together to keep children and young people safe in safeguarding Hub Single Contact FormContact reference:Click here to enter details:Forename(s):Click here to enter :Click here to enter title:Click here to enter :Click here to enter :Click here to enter :Click here to enter telephone number:Click here to enter with child/family:Click here to enter :Parental consent given?Click here to enter No , have the child/childrensuffered or likely to suffer significantharm?Click here to enter not at risk of serious harm, whyparental consent has not been here to enter this a follow-up from a telephonereferral?
2 Click here to enter safeguarding HubContact reference: Click here to enter text. Page 2 Child / young person / unborn baby details:Forename(s):(For unborn baby: UBB )Click here to enter :(For unborn baby: mother s surname or anyprevious names)Click here to enter of Birth/ Estimated Date ofDelivery:Click here to enter :Click here to enter Status:Click here to enter Address:Click here to enter Address:Click here to enter :Click here to enter here to enter Issues? Asylum seeker:Click here to enter here to enter s first language:( N/A if preverbal)Click here to enter Number:Click here to enter Pupil Number:Click here to enter required:Click here to enter required:Click here to enter :Click here to enter :Click here to enter , address and Contact details ofGP:Click here to enter , address and Contact details ofHealth Visitor/School Nurse:Click here to enter of Early YearsSetting/School/College and ContactPerson.
3 Click here to enter safeguarding HubContact reference: Click here to enter text. Page 3 Parent(s)/carer details:Full NameDate of BirthAddress(if different from the child)TelephoneGenderParental responsibilityFamily composition / significant othersFull NameDate of BirthAddressTelephoneGenderRelationship to child/children namedpreviouslyIs this a child that is also beingreferred?What is the reason for this Contact ?What are the concerns?Click here to enter of response:Click here to enter outcome:Click here to enter safeguarding HubContact reference: Click here to enter text.
4 Page 4 What is the seriousness of these concerns?Analysis of risk:Please explain the level of risk and impact on the child/children including the risk score from the riskassessment tool (if applicable):Click here to enter and OutcomesDetails of any previous actions taken and associated outcomesHow have the current concerns with the child and family been addressedClick here to enter Agencies / ServicesName of professionaland organisationContact details Brief description of workundertaken or ongoingsupport (if known)Has an Early Help Assessment beencompleted on this child or youngperson?
5 Click here to enter here to enter text.