Early Help Referral Form
Please use this form to make referrals to Oldham's Multi-Agency Safeguarding Hub (MASH) for: . individuals or families needing support from Early Help, or . children and young people needing support with mental health issues IMPORTANT NOTICE In order to make decisions about referrals, and to refer individuals or families to the most appropriate services, partner organisations in the MASH need to share information with each other. This may include personal data supplied on this form, and other information relevant to the referral. Please confirm at the end of the form that the individual / family have consented to the referral being made, and to the sharing of information between partner organisations in the MASH. If you are making a self-referral please check the box at the end of this form giving consent for data sharing.
Details Of Referrer Completing This Form Name:   Job Title:   Agency:   Address:   Postcode: Landline: Mobile: Email:    
Household Details
Primary Individual Forename:   Surname:   DOB:   Gender: Ethnicity: GP Surgery: NHS No:
First language of family: Is an interpreter required? Family Address:   Postcode: Landline: Mobile: Housing Provider: Tenure: Referral Issue:   What has been done already, and what agencies have been involved?   What is required?   For Healthy Young Minds referrals ONLY - is there any reason for this referral to be particularly urgent? Are you aware of any current issues/risks for this family/client?   (If yes, please provide further information below)  
Additional Individuals
Additional Individual 1 Forename:   Surname: DOB: Gender: Ethnicity: Relationship:
Additional Individual 2 Forename:   Surname: DOB: Gender: Ethnicity: Relationship:
Additional Individual 3 Forename:   Surname: DOB: Gender: Ethnicity: Relationship:
Additional Individual 4 Forename:   Surname: DOB: Gender: Ethnicity: Relationship:
Additional Individual 5 Forename:   Surname: DOB: Gender: Ethnicity: Relationship:
Additional Individual 6 Forename:   Surname: DOB: Gender: Ethnicity: Relationship:
Additional Individual 7 Forename:   Surname: DOB: Gender: Ethnicity: Relationship:
Additional Individual 8 Forename:   Surname: DOB: Gender: Ethnicity: Relationship:
Are the family aware of the referral? Has consent been given to the referral and information sharing? Has an Early Help assessment already been completed for this household? (If yes, a copy may be required prior to commencement of the service)      

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