Request for Family Support

 

Please use the form below to tell us about a person or family who may need some help and support from Cooperative Working.

 

Safeguarding: If you are concerned that an infant, child or young person has been harmed or abused or is at risk of being harmed or abused, you must follow the Safeguarding Children’s Board safeguarding children procedures. You can find up to date procedures and guidance at www.safeguardingchildren.stoke.gov.uk or contact us on:

  • During office hours - Safeguarding Referral Team 01782 235100 (select option 3)

  • Out of hours - Emergency Duty Team 01782 234234

Fields marked with a * are required fields

If you have a referral form or other documentation you wish to include with your referral, please use the section below to upload it.
  Upload one file only
   Upload File  
 

SECTION A – About you

*Your name
*Role
   Agency (where applicable)
   Location/ base (where applicable)
*Contact Number (landline)
   Contact Number (mobile)
*Email Address

SECTION B – About the Family/ Case

 
Referrals will not be accepted without consent. Please obtain consent before the referral is submitted to prevent unnecessary delays.  
*Has consent been obtained?
 

Address of the family

 
*House Number/Name
*Street
*Area
*Post Code
*Contact Number (landline)
 

Family Members

 First Name Surname Relationship Date of Birth or Expected Due Date Ethnicity Gender
 If this customer/family are known to social care please provide the name of the social worker
 Please outline the ongoing support needs of the customer/family (be as detailed as possible as missing information may delay the referral)
  Please detail work already completed and state the name of any other agencies involved
  Do you know which agency you want this information to be sent to?
  If Yes, please state which one
 Have you completed an Early Help Assessment?
  Is there an Early Help open?

 

 

Stoke-on-Trent City Council, Civic Centre, Glebe Street, Stoke-on-Trent ST4 1HH, UK rgin-l-50">Telephone: +44 (0)1782 234234Email: Council, Civic Centre, Glebe Street, Stoke-on-Trent ST4 1HH, UK rgin-l-50">Telephone: +44 (0)1782 234234Email: enquiries@stoke.gov.uk