MARF Form Before you start - help with assessing levels of need Simply pick the appropriate level in response to each question. The answers will then offer guidance on what course of action to take. Use the level of need online slider 1Checks 2Concerns 3Children 4Parents / carers 5Agencies 6Referrer 7Confirmation Progress Checks Before you fill in this form you must confirm the following My concerns meet level 4 of the level of need criteria yes No You cannot proceed unless the concern meets level 4 of the level of need criteria I have gained consent from the child’s parent or carer yes No If you fail to gain parental consent for a referral for a Child in Need Assessment when there are no safeguarding concerns, your request will be rejected. Please give the reason why you were unable to seek consent. I believe the child is at risk of significant harm if I ask for consent. The reason I believe this is Please name the parent or carer who has given consent Has the parent or carer read this statement on how we use and share data yes No Has the parent or carer asked for information not to be shared with any of the following agencies? Police Health GP School nurse Health visitor Housing Education / Nursery Probation Youth offending service Other Please provide details of other agencies I understand that, whenever it’s possible, I must include the views of the parent, carer and child in this referral as their voice will inform the assessment process and result in the most appropriate type of intervention. yes If this is a Section 47 Child Protection Referral please confirm you have made a telephone referral to Careline yes No N/A Please explain why you have not made a telephone referral to Careline Concerns Have you undertaken an Early Help Assessment in the last 12 months? yes No Please state why you feel it is not necessary Please attach a copy of the form Have you considered indicators of neglect using GCP2 yes no Please upload a copy of the GCP2 document Have you considered indicators of neglect using another tool? yes no What reason can you give for not giving consideration to indicators of neglect? Please upload a copy of the tool Referral Reason(s) CAFCASS request for Information Child Death Child Sexual Exploitation (CSE) Child Criminal Exploitation (CCE) Criminal Exploitation Domestic Violence / Domestic Abuse Drug Alcohol Use Emotional Abuse Fabricated or Induced Illness (FII) Female Genital Mutilation Forced Marriage Gun and Gangs Homeless Honour Based Violence Learning Disability Mental Health Missing Neglect Physical Abuse Physical Illness / Disability Radicalisation Sexual Abuse Unaccompanied Asylum Seeker Unaccompanied Minor Unauthorised Absence Young Carer Is a Young Carers Assessment Required? yes no Please state whether the following are applicable to this young person, If you are not selecting any of these indicators, please consider if a CSE or CCE specific referral needs to be made. Regularly missing Parents / Carers not reporting young person missing Drug or alcohol misuse Has extra money/new items/‘gifts’ that cannot legitimately be accounted for/received from unknown sources Change in physical appearance or behaviour Pregnancy, termination or repeat testing for sexually transmitted infections Young person has been coerced to take/share indecent images Arrested/Involved in criminality Found / travelling out of Borough Multiple mobile phones Young person feels indebted to an individual or group Family or young person having to move or leave their home Items missing from home Young person carrying / concealing weapons Associates known to be involved in criminality or Organised Crime Groups (OCGs) Absent from school / Non-school attendance Services have not been able to engage with child Living in a chaotic / dysfunctional household Low self-esteem / self confidence Association with others who have been exploited Self-harm indicators and/or mental health concerns and/or suicidal thoughts/attempts Injuries – evidence of physical or sexual assault Relationship breakdown with family and or peers Homeless Young person has limited age appropriate friendships Association with older and/or risky peers Young Carer Change in education attendance/Change in education provider/Missing from education/Non-attendance in education Young person's sexuality increases their vulnerability as they feel unaccepted due to sexual orientation Evidence for above tick answers and reason for referral (please give as much information as possible) CSE/CCE Suspected perpetrator details Forename(s) Don't know Surname / Family Name(s) Don't know Gender -- Please select -- Female Indeterminate (medical condition) Male Non binary Don't know Ethnicity * -- Please select -- White – British Not known at this stage Black background Any Other Ethnic Group Mixed – Any other mixed background Asian background Asian/Asian British – Any other Asian/Asian British - Bangladeshi Asian/Asian British - Indian Asian/Asian British - Pakistani Black/Black British - African Black/Black British – Any other Black/Black British - Caribbean Chinese Mixed – White and Asian Mixed – White and Black African Mixed – White and Black Caribbean White – Any other white background White – Gypsy/Roma White – Irish White – Traveller of Irish Heritage Don't know Approximate age Don't know Relationship to Child * Don't know Postcode Don't know Use the postcode look-up button to find your address Select Address -- Please Select -- Lookup Postcode Searching... Address (only use if the address is not available using the Lookup Postcode button) What are you worried about? What change needs to happen? Have you had direct contact with the child? yes no What did the child say or what are your observations of the relationship between carer and child? What does the child want to happen? What support has been given to the family thus far and what the families strengths are? Children Is the child already known to Social Services? yes no First name Surname Other Names / Aliases - optional DOB (dd/mm/yyyy format) Or Approximate Age Postcode Use the postcode look-up button to find your address Select Address -- Please select -- Lookup Postcode Searching... Address (only use if the address is not available using the Lookup Postcode button) The address is Home Other family member address Foster care Children's Home Semi-Independent Hostel Secure unit Other Please state the address type Gender -- Please select -- Female Indeterminate (medical condition) Male Non binary Unknown / Unborn Ethnicity -- Please select -- White – British Not known at this stage Black background Any Other Ethnic Group Mixed – Any other mixed background Asian background Asian/Asian British – Any other Asian/Asian British - Bangladeshi Asian/Asian British - Indian Asian/Asian British - Pakistani Black/Black British - African Black/Black British – Any other Black/Black British - Caribbean Chinese Mixed – White and Asian Mixed – White and Black African Mixed – White and Black Caribbean White – Any other white background White – Gypsy/Roma White – Irish White – Traveller of Irish Heritage Nationality -- Please select -- British Polish Romanian Nigerian Libyan Afghan Albanian Algerian American Andorran Angolan Antiguans Argentinean Armenian Australian Austrian Azerbaijani Bahamian Bahraini Bangladeshi Barbadian Barbudans Batswana Belarusian Belgian Belizean Beninese Bhutanese Bolivian Bosnian Brazilian Bruneian Bulgarian Burkinabe Burmese Burundian Cambodian Cameroonian Canadian Cape Verdean Central African Chadian Chilean Chinese Colombian Comoran Congolese Costa Rican Croatian Cuban Cypriot Czech Danish Djibouti Dominican Dutch East Timorese Ecuadorean Egyptian Emirian Equatorial Guinean Eritrean Estonian Ethiopian Fijian Filipino Finnish French Gabonese Gambian Georgian German Ghanaian Greek Grenadian Guatemalan Guinea-Bissauan Guinean Guyanese Haitian Herzegovinian Honduran Hungarian Icelander Indian Indonesian Iranian Iraqi Irish Israeli Italian Ivorian Jamaican Japanese Jordanian Kazakhstani Kenyan Kittian and Nevisian Kuwaiti Kyrgyz Laotian Latvian Lebanese Liberian Liechtensteiner Lithuanian Luxembourger Macedonian Malagasy Malawian Malaysian Maldivan Malian Maltese Marshallese Mauritanian Mauritian Mexican Micronesian Moldovan Monacan Mongolian Moroccan Mosotho Motswana Mozambican Namibian Nauruan Nepalese Netherlander New Zealander Nicaraguan Nigerien Ni-Vanuatu North Korean Northern Irish Norwegian Omani Pakistani Palauan Panamanian Papua New Guinean Paraguayan Peruvian Portuguese Qatari Russian Rwandan Saint Lucian Salvadoran Samoan San Marinese Sao Tomean Saudi Scottish Senegalese Serbian Seychellois Sierra Leonean Singaporean Slovakian Slovenian Solomon Islander Somali South African South Korean Spanish Sri Lankan Sudanese Surinamer Swazi Swedish Swiss Syrian Taiwanese Tajik Tanzanian Thai Togolese Tongan Trinidadian or Tobagonian Tunisian Turkish Tuvaluan Ugandan Ukrainian Uruguayan Uzbekistani Venezuelan Vietnamese Welsh Yemenite Zambian Zimbabwean Child's UPN number Child's NHS number Having UPN and NHS numbers for a child's record is important and allows us to link in with partner agencies and improve the quality of information we hold on children. Please provide these numbers if known. Religion -- Please select -- Not Known Not Stated None Roman Catholic Muslim Agnostic Atheist Bahai Faith Buddhist Church of England Hindu Jehovah’s Witness Jewish Methodist Non-conformist Other Christian Other religion Quaker Rastafarian Sikh Spiritualist Language spoken -- Please select -- English Arabic Not Disclosed Romanian Afghani Akan Albanian Amharic Arawak Ateso Bahasa Indonesia Bahasa Malysia Bajuni Bangala Bangli Bari Pojolu Bengali Bini British Sign Language Cantonese Chewa Chichewa Chinese - Cantonese Chinese - Hakka Chinese -Mandarin Coorge Creole English Creole French Czech Danish Dioula Doric Duri Dutch Ewe Farsi (Persian) Filipino Finnish Flemish French Friesian Gaelic (Irish) Gaelic (Scottish) Georgian German Goran Greek Gujarati Guyanese Creole English Hausa Hebrew Hindi Hokkien Igala Igbo Ikwere Isoko Italian Japanese Kagoro Kaonde Katchi Kikuyu Kinyarwanda Kirundi Kiswahili Kodagu Koli, Kachi Korean Kurdish Kutchi Lao Lingala Lingola Lithuanian Luganda Magyar Malay Maltese Mandarin Chinese Mauritian Creole (Morisyen) Mazandarani Memmoni Memni Northern Sotho Norwegian Other Language Panjabi Pashto Pashtu Persian Polish Portuguese Punjabi Pushto Pushtu Romany Russian Serbo-Croat Shanghainese Shona Sinhala Siswati Slovak Somali Spanish Swahili Swedish Tagalog Tamil Telugu Tgrina Thai Tigrigna Tiv Tongan Tswana Turkish Twi Unclassified Urdu Vietnamese Walloon Welsh Yiddish Yoruba Is an interpreter required? yes no Does the Child have any disability? yes no Please highlight the impact of the disability on the child Nature of disabilities Behaviour Communication Consciousness Diagnosed with Autism or Asperger's Disabled under DDA but not in the other categories Hand function Hearing Incontinence Learning Mobility Personal Care Syndrome Unknown at this time Vision Is in school or nursey? yes no School / Nursery Not in Education, Employment or Training (NEET) yes no GP Name Surgery address Immigration Status -- Please select -- Asylum Seeker Discretionary Leave to Remain in the UK to 18 (DUR) DLR to 18th Birthday, extension applied for Exceptional Leave to Remain in the UK (ELR) Exhausted Asylum Appeals Humanitarian Protection applied for under ECHR Indefinite Leave to Remain in the UK (ILR) Refugee Status Refused Asylum, Appeal applied for Returned home or Deported Unaccompanied Aylumn Seeking Child Is this child placed from a different Local Authority? yes no Name of Local Authority What date have they been placed since? - optional Add siblings, including step children Parents / carers First name Surname Relationship to child -- Please select -- Brother Carer Father Grandparent Mother Other Sister Has parental responsibility? yes no Who has parental responsibility? First name Surname Copy the first child's address Postcode Use the postcode look-up button to find your address Select Address -- Please select -- Lookup Postcode Searching... Address (only use if the address is not available using the Lookup Postcode button) Telephone - optional Email - optional If known please specify a telephone number or an email address Gender -- Please select -- Female Indeterminate (medical condition) Male Non binary Unknown / Unborn DOB (dd/mm/yyyy format) Or Approximate Age Ethnicity -- Please select -- White – British Not known at this stage Black background Any Other Ethnic Group Mixed – Any other mixed background Asian background Asian/Asian British – Any other Asian/Asian British - Bangladeshi Asian/Asian British - Indian Asian/Asian British - Pakistani Black/Black British - African Black/Black British – Any other Black/Black British - Caribbean Chinese Mixed – White and Asian Mixed – White and Black African Mixed – White and Black Caribbean White – Any other white background White – Gypsy/Roma White – Irish White – Traveller of Irish Heritage Nationality -- Please select -- British Polish Romanian Nigerian Libyan Afghan Albanian Algerian American Andorran Angolan Antiguans Argentinean Armenian Australian Austrian Azerbaijani Bahamian Bahraini Bangladeshi Barbadian Barbudans Batswana Belarusian Belgian Belizean Beninese Bhutanese Bolivian Bosnian Brazilian Bruneian Bulgarian Burkinabe Burmese Burundian Cambodian Cameroonian Canadian Cape Verdean Central African Chadian Chilean Chinese Colombian Comoran Congolese Costa Rican Croatian Cuban Cypriot Czech Danish Djibouti Dominican Dutch East Timorese Ecuadorean Egyptian Emirian Equatorial Guinean Eritrean Estonian Ethiopian Fijian Filipino Finnish French Gabonese Gambian Georgian German Ghanaian Greek Grenadian Guatemalan Guinea-Bissauan Guinean Guyanese Haitian Herzegovinian Honduran Hungarian Icelander Indian Indonesian Iranian Iraqi Irish Israeli Italian Ivorian Jamaican Japanese Jordanian Kazakhstani Kenyan Kittian and Nevisian Kuwaiti Kyrgyz Laotian Latvian Lebanese Liberian Liechtensteiner Lithuanian Luxembourger Macedonian Malagasy Malawian Malaysian Maldivan Malian Maltese Marshallese Mauritanian Mauritian Mexican Micronesian Moldovan Monacan Mongolian Moroccan Mosotho Motswana Mozambican Namibian Nauruan Nepalese Netherlander New Zealander Nicaraguan Nigerien Ni-Vanuatu North Korean Northern Irish Norwegian Omani Pakistani Palauan Panamanian Papua New Guinean Paraguayan Peruvian Portuguese Qatari Russian Rwandan Saint Lucian Salvadoran Samoan San Marinese Sao Tomean Saudi Scottish Senegalese Serbian Seychellois Sierra Leonean Singaporean Slovakian Slovenian Solomon Islander Somali South African South Korean Spanish Sri Lankan Sudanese Surinamer Swazi Swedish Swiss Syrian Taiwanese Tajik Tanzanian Thai Togolese Tongan Trinidadian or Tobagonian Tunisian Turkish Tuvaluan Ugandan Ukrainian Uruguayan Uzbekistani Venezuelan Vietnamese Welsh Yemenite Zambian Zimbabwean Religion -- Please select -- Not Known Not Stated None Roman Catholic Muslim Agnostic Atheist Bahai Faith Buddhist Church of England Hindu Jehovah’s Witness Jewish Methodist Non-conformist Other Christian Other religion Quaker Rastafarian Sikh Spiritualist Language spoken -- Please select -- English Arabic Not Disclosed Romanian Afghani Akan Albanian Amharic Arawak Ateso Bahasa Indonesia Bahasa Malysia Bajuni Bangala Bangli Bari Pojolu Bengali Bini British Sign Language Cantonese Chewa Chichewa Chinese - Cantonese Chinese - Hakka Chinese -Mandarin Coorge Creole English Creole French Czech Danish Dioula Doric Duri Dutch Ewe Farsi (Persian) Filipino Finnish Flemish French Friesian Gaelic (Irish) Gaelic (Scottish) Georgian German Goran Greek Gujarati Guyanese Creole English Hausa Hebrew Hindi Hokkien Igala Igbo Ikwere Isoko Italian Japanese Kagoro Kaonde Katchi Kikuyu Kinyarwanda Kirundi Kiswahili Kodagu Koli, Kachi Korean Kurdish Kutchi Lao Lingala Lingola Lithuanian Luganda Magyar Malay Maltese Mandarin Chinese Mauritian Creole (Morisyen) Mazandarani Memmoni Memni Northern Sotho Norwegian Other Language Panjabi Pashto Pashtu Persian Polish Portuguese Punjabi Pushto Pushtu Romany Russian Serbo-Croat Shanghainese Shona Sinhala Siswati Slovak Somali Spanish Swahili Swedish Tagalog Tamil Telugu Tgrina Thai Tigrigna Tiv Tongan Tswana Turkish Twi Unclassified Urdu Vietnamese Walloon Welsh Yiddish Yoruba Is an interpreter required? yes no Add principal carer Other Significant adults in household (if known). Please include relationship and DOB if known - optional Agencies In the below table please provide the details of practitioners working with the child/family. Agency Name Telephone Email Address GP Health Visitor School Nurse Community Mental Health Community Paediatrician Midwife Substance Misuse Worker Domestic Abuse Worker YOT Worker Early Help Worker Voluntary Worker CAMHS Probation MAPPA Lead practitioner name No Lead Agency Early Help Plan Child in need Child Protection Plan LAC / Leaving Care Lead practitioner name Referrer First name Surname Job Title/Role Organisation Source type -- Please select -- Education Services Health Services – School Nurse Health Services – A&E Health Services – GP Health Services – Health Visitor Health Services – Other (eg hospice) Health Services – Other Primary Health Services Housing Individual – Acquaintance (including neighbours and child minders) Individual – Family member/ relative / carer Individual – Other (including strangers, MPs) Individual – Self LA Services – External LA Services – Other internal LA Services – Social Care Other – Including Children’s Centres, independent Agency Providers, Voluntary Organisations Other – Legal Agency – including courts, probation, immigration, CAFCASS, prison Police Schools Unknown Telephone Mobile - optional Email Preferred Method Of Contact -- Please select -- Telephone Email Mobile Letter Please specify who should receive feedback about the outcome of this referral. 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