Professional Referral

Referrer Name

Referrer Agency and Job Title

Referrer Email

Referrer Contact Number

Dads Name

Dads Contact Number

Dads Email

Dads Date of Birth

Dad's Address

Dads Postcode

Dads Ethnicity

Number of Children

DOB or Due Date of Youngest Child

When Is The Best Time To Contact You?

Any Information You Wish To Share

I hope that Dad Matters will help meet the following needs (please tick) I hope that Dad Matters will help meet the following needs (please tick) Develop awareness of attachment and bonding. Support to access and understand local and national services available to Dad/parenters. Accessing peer support from other Dads. To better understand stress and its impact on the family. Ante-natal parenting support. Post-natal parenting support. Increased confidence in being a parent. Dads mental health issues. Partners mental health issues. Dads general physical health issues. Dads learning needs Other

If other, please specify.

Is there any current risk that could place a staff member or volunteer at risk? (DA, anti-social behaviour, home conditions, pets, gangs, smoking, drug use). Is there any current risk that could place a staff member or volunteer at risk? (DA, anti-social behaviour, home conditions, pets, gangs, smoking, drug use). Yes No

If yes, please specify.

Doctors Details

Health visitors/midwife details

Social worker contact details

Early help/other lead professional contact details.

Current Safeguarding in the family. Are the family on a plan? Current Safeguarding in the family. Are the family on a plan? Develop awareness of attachment and bonding. Early Help Children in Need Child Protection Specialist Case Planning Vulnerable Babies None

Please provide details of any support Dad has received from PIMH pathway... E.g. CAPS NHS,

Other Agencies referred to.

Are any family members within the household already being supported by Home-Start St Helen? Are any family members within the household already being supported by Home-Start St Helen? Yes No

When is the best time to Contact Dad?

Confirmation Confirmation I confirm Dad has agreed to this referral.