connection to this support and that such practitioners might include, amongst others, family workers, youth workers, teachers, doctors, psychologists, nurses, therapists and social workers. Name of Relationship Any First Gender Ethnic school or Signature of Last name DOB e.g. mother, declared name (M/F) origin workplace consent father, disability (include NI) (Please state in signature box above to indicate signed copy held locally) ‘yes’ Individuals or agencies you do not wish information to be Information you do not want to be shared shared with. Please give reasons why. IMPORTANT: The main family contact needs to sign beside any member of the family that is aged 15 or under*. Any family member over the age of 16 needs to give consent by signing against their details. *A young person aged 12 or over, who has the capacity to understand and has sufficient understanding to make their own decisions, may give (or refuse) consent to sharing information. This should include an understanding of the question being asked, what information might be shared and implications of sharing that information. It is good practice to ensure you have their consent to share information and work with services. Additional information Details of other agencies / practitioners involved with the family (e.g. GP and School): Practitioner Job role/ Team/ Supporting which Contact details (work details only) Name Organisation family member
connection to this support and that such practitioners might include, amongst others, family workers, youth workers, teachers, doctors, psychologists, nurses, therapists and social workers. First name Last name DOB Gender (M/F) Relationship e.g. mother, father, Ethnic origin Any declared disability Name of school or workplace (include NI) Signature of consent (Please state ‘yes’ in signature box above to indicate signed copy held locally) Individuals or agencies you do not wish information to be shared with. Please give reasons why. Information you do not want to be shared IMPORTANT: The main family contact needs to sign beside any member of the family that is aged 15 or under*. Any family member over the age of 16 needs to give consent by signing against their details. *A young person aged 12 or over, who has the capacity to understand and has sufficient understanding to make their own decisions, may give (or refuse) consent to sharing information. This should include an understanding of the question being asked, what information might be shared and implications of sharing that information. It is good practice to ensure you have their consent to share information and work with services. Additional information Details of other agencies / practitioners involved with the family (e.g. GP and School): Practitioner Name Job role/ Team/ Organisation Supporting which family member Contact details (work details only)
Early-Help-Notification-Form.docx