Dad Matters Referral Enquiry Form Dad Matters Referral Enquiry Form Referrer Name(Required) Referring agency and job title(Required) Referrer Email(Required) Referrer Contact number(Required) Dad's Full Name(Required) Dad's Contact number(Required) Dad's Email Dad's Address(Required)Dad's date of birth(Required) DD slash MM slash YYYY Dad's ethnicity(Required) Number of Children(Required)Please enter a number greater than or equal to 0.Date of Birth of the youngest child/Expected due date (if applicable)(Required) DD slash MM slash YYYY I hope that Dad Matters will help meet the following needs (please tick)(Required) Develop awareness of attachment and bonding Support to access and understand local and National services available to dads/partners Accessing peer support from other dads/partners To better understand stress and its’ impact upon the family Ante-natal parenting support Post-natal parenting support Increased confidence in being a parent Own mental health issues Partner’s mental health issues Own general physical health issues Parents’ own learning needs Other (please specify below) Other support needsIs there any current risk that could place a staff member or volunteer at risk? (DVA, anti-social behaviour, home conditions, pets, gangs, smoking, drug use)(Required) Yes No If you answered yes above please provide more information regarding any riskFamily Doctor & Contact Details(Required) Health Visitor/Midwife Contact Details(Required) Social Worker Contact Details(Required) Early Help/Other Lead Professional Contact Details(Required) Current safeguarding in the family. Are the family on a plan?(Required) Early Help Children in Need Child Protection Specialist Case Planning Vulnerable Babies None Please provide details of any support Dad has received from the PIMH pathway… E.g. CAPS, NHS Talking Therapies, etc.(Required)Other Agencies Referred to(Required) Are any family members within the household already being supported by Home-Start Manchester?(Required) Yes No ‘Does Dad live with the child/children full time?(Required) Yes No Please indicate a suitable time for someone to contact Dad:(Required) Morning Afternoon Evening Anytime Confirmation(Required) I Confirm Dad has Agreed to This Referral
