HomeCSPOA FORM CSPOA FORM 1. ConsentHave you informed the parent/carer that you are making this contact? Yes No Have they given consent for this contact? Yes No Do they have parental responsibility for all children in the household? Yes No Who gave consent? Consent given as Verbal Written If no consent tell us whyHave you informed the child/young person that you are making contact? Yes No Have they given consent for this contact? Yes No Verbal consent? Yes No If no consent tell us why2. The children and young people in the family home Section 2Surname (other names)* Forename* Any other names used Date of birthDay12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Ethnicity Religion (if applicable) Gender* Male Female Language spoken at home Interpreter required? Yes No Does the child have a disability? Yes No If yes, please provide details: Present postcode* Present addressPrevious Address if from outside area or at present address less than 1 year:GP details NHS number UPN Present school/preschool/children's centre/nursery AddressPresent school/preschool/children's centre/nurseryHeadteacher Class/form teacher Email address of designated/safeguarding contact(Present school/preschool/children's centre/nursery) Telephone number of designated/safeguarding contact(Present school/preschool/children's centre/nursery) Add Child/Young PersonRemove Child/Young Person3. Parent/carer’s details Section 3Surname (other names)* Forename* Any other names used Date of BirthDay12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender* Male Female Relationship to child/children Parental responsibility* Yes No Main carer for the child* Yes No Religion (if Applicable) Language Spoken at Home Does the carer have a disability?* Yes No If yes, please provide details: Present Address (if different from child)GP Details NHS Number Parent/carer's email address Parent/carer's phone NumberName of Workplace (if known) Add Parent/CarerRemove Parent/Carer4. Significant other people to the family e.g. grandparents, aunt, uncle, siblings not living in the same household Section 4Surname (other names) Forename Any other names used Date of BirthDay12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender Male Female Relationship to child/children Religion (if something to consider with the family) Ethnicity Language Spoken at Home Interpreter required Yes No Email address Phone NumberAdd Significant OtherRemove Significant Other5. Previous supportHas there been previous social worker involvement Yes No Unknown If yes, was this in Reading Yes No Dates Have early help arrangements been initiated for this family? Yes No Unknown If yes, was this in Reading? Yes No Are or were the following in place (tick all that apply) Select All Early Help assessment Team Around the Child/Family Plan Team Around the Child/Family group and meetings Lead professional/key worker Name of lead professional/key worker 6. Agencies/organisations/services involved with the family Section 5Agency type Name of agency/practitioner Role Address & postcodeEmail address Phone numberDetails of InvolvementAdd organisation/agencyRemove organisation/agency7. Risk factorsRisk FactorsPlease tick all that apply Alcohol misuse by child/young person Alcohol misuse by parent/carer/adult in household Anti-social behaviour Child exploitation (sexual & criminal) Domestic Violence Drug misuse by child/young person Drug misuse by parent/carer/adult in household Emotional abuse Fabricated illness Family in acute stress Female genital mutilation Forced Marriage Offending Homeless young person Honour based violence Learning disability of child/young person Learning disability of parent/carer/adult in household Missing from home Missing from school/education Mental health of child/young person Mental health of parent/carer/adult in household Neglect Physical disability or illness of parent/carer/adult in household Physical abuse Physical disability or illness of child/young person Private Fostering Radicalisation Sexual abuse Self-harming Trafficking Unaccompanied Asylum-Seeking Child (UASC) Young Carer Other risk factor 8. Tell us about what life is like for this child/children/young person and their familyReason for referral. Why are you worried about this child/family?Does the family share your worries? Please describe facts including frequency, severity and impact. What are the specific behaviours of the parents/child/young person that may pose a risk to their welfare or safety?What is the impact on the child/young person?How is this affecting the child’s health, development and wellbeing? What are you worried will happen if nothing changes?What help or support has already been put in place for this family and what is the outcome?Tell us about how you, other services or extended family have been supporting the family and the impact of this. Please describe the help, support and/or interventions, when they took place or if they are current and the impact or outcome.What is working well for this child and the family?What are the strengths/support systems within the family, the things they do well, the resources within the family that reduce the danger and the times where danger has been present, but the parents have been able to manage/reduce this danger?What level of intervention in line with the Reading Threshold document do you think Brighter Futures for Children can help this family with?9. Your detailsYour name* Organisation/agency of referral*IndividualSchoolsEducation servicesHealth servicesHousingLA servicesPoliceOther legal agencyOtherAnonymousUnknownYour role* Date Day Month Year Your phone number*Your email* A copy of the completed form details will be sent to this email.Have you discussed this contact with your safeguarding lead or line manager?* Yes No Their name (if relevant) Their title 10. Confirmation of Threshold of NeedWhat is your assessment of the Threshold of Need that this referral meets? Level 3 – Children's Social Care Level 2b – Target Early Help services provided by Brighter Futures for Children Level 2a – Early Help, partnership support Level 1 – Universal services If you have ticked Level 1 or 2a we will refer you to the partnership coordinator.
