Family Support Derbyshire
Please correct the following before sending:
Please note:

Referrals must be made with consent of the family and can only be accepted if Referrers Declaration is completed.


Phone number only, e.g. 01332 123456 or 07123 456789

Please provide some details about the adults caring for the child(ren):

Mother/Partner1
Father/Partner2
Other main carer 1

Referred by:





Doctor:


Health Visitor:


Details of Children - Please note the family must have at least one child of pre-school age (include all dependant children under 18 years)

Eldest First:

Child 1.
Child 2.
Child 3.
Child 4.
Child 5.
Child 6.

Details of other members of the household with responsibilities for caring for the children

GenderDoBImmigrationDisabledEthnicity
Main Carer
Partner living in household

Please use this section to provide any additional information that you think we would find useful and will support us when considering placing a volunteer. (i.e. Parents health needs/disabilities, Health and Safety issues, etc)

Family Needs

NeedYes/NoWhy?
School readiness requirements
Managing child’s behaviour
Being involved in the child(ren)’s development/early learning and socialisation
Coping with own physical health
Coping with own mental health
Coping with feeling isolated
Parent’s self-esteem
Coping with child’s physical health
Coping with child’s mental health
Managing the household budget
The day-to-day running of the house
Stress caused by conflict in the family
Coping with extra work of multiple children under 5
Use of other services
Other
Parents own learning needs

REFERRER’S DECLARATION

What do Family Support Derbyshire do?

Family Support Derbyshire offer a family support service to any family with a child under the age of 5 years for up to 1 year.Supported by paid staff, our volunteers use their parenting experience to support families with whatever issues they may face whilst raising young children.Volunteers and staff visit families in their own homes.

What data does Family Support Derbyshire collect, why, and for how long is it kept ?

Family Support Derbyshire collects data about the main carer(s) and the children of the families we support. When a family is referred to us we record the following personal information:

  • The family’s address and up to two contact phone numbers
  • Names, genders, dates of birth and ethnicities
  • Immigration statuses and disability statuses, if applicable
  • For children, the details of any additional needs and any safeguarding measures in place
  • The needs and difficulties the family would like support with. This might include specific details of individuals’ health and/ or circumstances.
  • The family’s use of other relevant services, such as doctors, children’s centres, libraries, etc.
  • Whether or not there are any health and safety concerns about visiting the family.

We collect this data at the point of referral so that we can provide a tailored befriending service to a family in their own home.This includes our need to ensure a safe working environment for our staff and volunteers and to produce anonymous statistical reports, which are needed to secure funding.Data is stored for 1 year following the end of Family Support Derbyshire’s support, unless there were any safeguarding concerns raised, in which case it is kept for 6 years.

Consent

Family Support Derbyshire processes referrals on the basis of families’ consent. Accordingly, families can withdraw consent at any time, although this will mean we have to end our support for them.

REFERRER’S DECLARATION:

I have spoken directly to the named main carer(s) on this referral and on the I explained to them the full contents of this document. By signing below I declare that the main carer(s) understand what data Family Support Derbyshire will be sent, and what will be done with their data once a referral is made to Family Support Derbyshire.