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Positive Futures Parenting Support Course Referral Form (Professionals)
Thank you for taking the time to complete this referral form. Once this form is completed and submitted we will make contact to allocate a course place. The information you submit is held securely in accordance with GDPR requirements. The course is funded by City of York Council. If you have any questions or issues completing this form please contact
enquiries@brightsparkscic.org.uk
or call 01904 500301
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* Indicates required question
Referral made by (name):
*
Your answer
Referral organisation:
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Your answer
Email address of referrer:
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Your answer
Telephone number of referrer:
*
Your answer
Family details - please provide the name of the parent/carer wanting to attend the programme:
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Your answer
Please provide the address of the parent/carer wanting to attend the programme:
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Your answer
Parent/carer telephone number:
Your answer
Parent/carer email address:
Your answer
Parent/carer gender:
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Female
Male
Prefer not to say
Other:
Parent/carer ethnicity:
*
Your answer
Family's first language
Your answer
Has the parent/carer consented to this referral?
Yes
No
Clear selection
Family details - please list the names the children in the household, their dates of birth, gender and current school:
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Your answer
Why are you referring this family onto this parenting support programme? Please provide relevant details on current family and home situation:
Your answer
What issues would you like this programme to address?
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Your answer
What are the parents/carers views of the referral and or/the support being offered through this referral?
Your answer
What does the parent/carer hope/want to achieve from this programme?
Your answer
Other needs and/or requirements - is there anything else happening that you think would be helpful for us to know about?
Your answer
Are there any special requirements/barriers to engagement that need to be considered e.g. problems with literacy, mobility issues, areas of concern we should be aware of?
Your answer
Any additional information or comments:
Your answer
How did you hear about the parenting support course?
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City of York Council Local Area Team
York Family Information Service
Word of mouth
Advertising/social media
Other
Which location would they ideally like to attend?
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Please note we will be running 6 courses throughout the academic year (Sept 2018 - July 2019). The remaining 2 course location and dates will be arranged based on need. Please feel free to email
enquiries@brightsparkscic.org.uk
if the parent/carer has a particular location need or other requirement.
Vale of York Academy, Clifton (Starts Tuesday 25th September 2018 - 9.30-11.30am, 10 week course, 2 hrs per week term time only)
Hob Moor Children's Centre, Acomb (Starts Thursday 10th January 2019 - 9.30-11.30am 10 week course, 2 hours per week term time only)
The Avenues Children's Centre, Tang Hall (Starts Thursday 4th April 2019 - 9.30-11.30am 10 week course, 2 hours per week, term time only)
York Council Offices City Centre (Starts Tuesday 7th May 2019 - 6pm - 8pm for 10 weeks, 2 hours per week term time only )
Clifton Children's Centre, Clifton (starts Friday 5th March 2019 - 10am-12pm, 2 hours per week for 10 weeks terms time only)
Other/don't know
Other:
Do they have children who are eligible for two year old funding? (childcare funding)
Yes
No
Maybe
Not applicable
Other:
Clear selection
Are their children eligible for free school meals?
Yes
No
Not sure
Clear selection
Are they on a Child Protection Plan?
Yes
No
Prefer not to say
Other:
Are they responsible for Looked After Children?
Yes
No
Prefer not to say
Other:
Clear selection
Do they have a Family Early Help Assessment or have one under development?
Yes
No
Under development
Prefer not to say
Clear selection
I confirm that the information contained in this form is accurate and I wish to secure a place on this course, on behalf of the person listed above.
*
I agree
Required
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