Multi Agency Referral

Please complete the following sections, and then submit the referral form by clicking the submit button at the foot of the page.

Initial Contact

You do not need consent to make a referral into MASH. However, it is our expectation that whenever it is safe to do so, you have a conversation with parents or care givers to explain why you are worried.

Have you had a conversation with parents or care givers?

Please be aware that it is best practice for practitioners to share their concerns with families prior to making a referral into children’s services. It is also important to explain that you intend to make a referral to MASH. If you have not had this conversation with parents or caregivers, a MASH practitioner may make contact with you to request this prior to your referral being accepted.

Have you completed an early help assessment?

Please note that it is best practice for professionals to offer support to families when they need it, and to capture your evaluation of need through an early help assessment. If you have not completed an early help assessment we may get in touch with you to request that you do so.

Person completing the referral details

Please ensure that you complete each section with accurate information.

First Name

Surname

Role

Organisation Name & Address

Telephone Number

Email Address

A confirmation email will be sent to this email address.

Email Address to receive the referral outcome if different from above

The referral outcome will be sent to this email address if different from the email address above e.g. Organisation Safeguarding Team email address

Child's details

Please complete with full & accurate information and ensure spelling and dates are correct.

To find an address, enter the search criteria in the Address Search and click 'Search', then select the required address from the dropdown list.

Address Search

Select Address

Only Solihull addresses are shown - if you can't find the address this means that you are not within the Solihull catchment area.

First Name

Surname

Date Of Birth

NHS Number

Ethnicity

Gender

Physical/learning difficulty/health conditions

Communication Needs

School/Education Details

Siblings/Other children in household/family

Please include any other children living in the same household, even if they are not directly related, also include any siblings that may be living in different households. Ensure all information is accurate; check spellings, dates and addresses.

Edit	First Name	Surname	DOB	Relationship	Delete
No details exist.

Parent/Carer details

Please include any other adults living in the same household, even if they are not directly related, also include anyone with parental responsibilities that may be living in different households. Ensure all information is accurate; check spellings, dates and addresses.

Edit	First Name	Surname	Relationship	Delete
No details exist.

Other agencies/professionals involved

Edit the existing entries in the list to add the relevant information, or delete them if appropriate. In addition, please include any professional that you know is working with the child, their siblings, parents/carers. Ensure all information is accurate; check names, email addresses and contact information.

Edit	Organisation	Named Person	Secure Email	Phone	Delete
	GP
	Early education and childcare setting
	School
	Health visiting/School nurse

Please tell us your concern

Please keep the referral as clear and concise as possible.

Only refer to concerns not previously referred to Solihull Children’s Services, a chronology will be requested if required.

Why are you worried about this child?

Is there harm or risk of harm? What has happened? Are there any wider concerns not previously shared with Solihull Children’s Services?

What is working well for this child?

What strengths can you identify for the child and their family network? What safety is in place? Who would the child consider to be their safe person/trusted adult? Are you aware of other significant people in the child’s network?

Tell us about the lived experience of the child - what is the impact on the child?

This can include wishes and views that they have shared with you (the voice of the child), observations of any changes in behaviours, observations or interactions with care givers, the conversation with the child to prompt Practioners

Upload documents

Please attach any documents supporting this referral, such as the Neglect screening tool, Barnardo's Domestic Violence Risk Identification Matrix (DVRIM), DASH, Exploitation screening tool, GCP2 etc. in this section. All documents uploaded with this referral will be shown in the grid below.

To upload a file, click the 'Choose File' button below, enter a description of the file and then press the 'Upload Document' button. You can upload files of a maximum size of 10MB. Only files of the following type may be uploaded: .pdf, .jpg, .png, .jpeg, .gif, .bmp, .doc, .docx, .txt, .xls, .xlsx

Enter a description of the file e.g. Completed screening tool

Description	Filename	Delete
No documents have been uploaded.

Submit Form

Please select the service that this referral should be sent to, tick the confirmation box and click on the 'Submit Form' button below when you have completed this referral form with all the information and details available to you.

Following this, you will shortly receive an e-mail at the secure email address entered above confirming this referral form has been sent securely.

If you do not receive this automated confirmation e-mail the referral form may not have been completed and therefore not sent. Please ensure you have submitted the form before exiting as it will not save the information.

Which service should receive this referral?

Please see the SSCP threshold document, which will help you determine which service you require. If you are unsure, please contact the Early Help phone line on 0121 788 4327 or the MASH on 0121 788 4300.

I confirm that this referral form is now completed and ready to be sent.

Multi Agency Referral Form

Is this an emergency situation? If so, call 999 for advice.