Home-Start Guildford

There for parents when they need us most, because childhood can't wait

Online Referrals

Who can we support?

We can support any parent living in Guildford Borough who has at least one child under the age of five and who wants our help. We provide free and confidential support to parents who are struggling to cope with a variety of challenging circumstances such as:

feeling isolated
suffering with post-natal depression and maybe finding it hard to talk to anyone about it
having a hard time coping with your child’s illness or disability
being affected by the death of a family member
struggling with the emotional and practical demands of twins, triplets or young children
finding it hard to cope with relationship difficulties
feeling exhausted or depressed
coping with your own illness or disability

Professional Referrals

If you are working with a family who you think could benefit from the support of Home-Start Guildford you should:

Discuss Home-Start with the family – they must agree to receive support.
Complete an Professional Referral Form (available online via our website or you can download the form and email/post it to our office).
Please complete as much information as possible, noting the mandatory entries.

When you have completed the online form, click on the submit button at the bottom to send it direct to our office.

Self Referrals

If you are a family requesting help for yourself, please click on the panel below called Online Self Referral Form. Fill in the form with as much information as possible, when you have completed the form, click on the submit button at the bottom to send the form direct to our office. If your application has been successful you will be taken to a “Thank you” page to confirm it has been submitted.

How to make a referral

Please click on either the Online Professional or Self Referral panel below. Fill in the form noting where there are mandatory entries and click on the submit button at the bottom to send the form direct to our office. If your application has been successful you will be taken to a “Thank you” page to confirm it has been submitted.

If you would prefer to complete a hard copy form, please select the Downloadable Professional or Self Referral panel and select the type of form you wish to download. You can send your completed form by email to office@hsguildford.org.uk or you can send it by post to the address listed on the form.

What happens next?

Once we have received a referral form, if you have sent a hard copy form, we will be in touch to let you know that it has been received. One of our co-ordinators will then contact the family in order to tell them more about Home-Start and how we might be able to help. When appropriate, the co-ordinator will arrange to visit the family in their home to discuss their support needs. We will make sure that the referrer is informed at every stage, including when the family is matched with a volunteer, and at each of their reviews and, finally, at the end of support.

Online Professional Referral Form

About this referral

All referrals must be made with the consent of the family. Have you discussed this referral with the family prior to completing this form?

Yes*

I confirm that the family has consented to this application

Services

Which of our service(s) is the family seeking?

Referring to:*Weekly support from a trained volunteerTo attend the Hazel Avenue family groupTo attend the Pirbright family group (Army families and local residents only)To attend the Baby Bubble Group at Hazel AvenueTo attend the Get Active with Your Little One

Select the service required

About the Referrer

Your name*

Please enter your full name

Job Title*

Please enter your job title

Date*

Date of this referral

Email Address*

Please enter your email address

Organisation*

Please enter the organisation you represent

Your contact number*

Please enter a number we can contact you on.

We may contact you from time to time to review and promote our service

Please confirm if you give consent to your contact details being held on our distribution list*I consentI do not consent

Mandatory entry

About the family seeking the service

All items marked in red are required to submit the form.

Parent/ Main Carer Name*

Please enter name of Parent/Main Carer

Email Address*

Please enter a valid email address we can use to contact them

Date of Birth*

dd/mm/yy

Family's Address*

Please enter the family's address here

Family's postal code*

Please enter their postal code so we can check they are in our area

Contact telephone number*

Please enter their contact number. It may help if this number can be used with WhatsApp

Parent/ Carer Ethnicity*

Other Adults Living with the Child/ Children

Name of Partner

Please enter the name of the partner (if relevant)

Date of Birth

dd/mm/yy

Please select ethnicity

Please make a selection from the list

List any other adults living in the home

Please enter details of any other adults in household

Other Agencies

Does the family have any statutory agencies involved?*

Mandatory entry, answer yes or no.

Children's Services

Select if applicable

Contact Name

Please enter the contact name

Contact number

Please enter a contact number

Intensive Support

Select if applicable

Contact Name

Please enter the contact name

Contact number

Please enter a contact number

Family Support Team

Select if applicable

Contact Name

Please enter the contact name

Contact number

Please enter a contact number

Family First Guildford (Family Centre)

Select if applicable

Contact Name

Please enter the contact name

Contact number

Please enter a contact number

Health Visitor

Select if applicable

Contact Name

Please enter the contact name

Contact number

Please enter a contact number

Parent Infant Mental Health

Select if applicable

Contact Name

Please enter the contact name

Contact number

Please enter a contact number

Perinatal Mental Health

Select if applicable

Contact Name

Please enter the contact name

Contact number

Please enter a contact number

Other

Select if applicable

Contact Name

Please enter the contact name

Contact number

Please enter a contact number

Please enter the details below for the child/ children, starting with the youngest child

Child 1 name*

Please enter the name of the youngest child

Child 1 Date of Birth*

Please enter the date of birth of the child dd/mm/yy

Child 1 Gender*

Please make a selection

Child 1 Ethnicity*

Mandatory Entry

Child 2 name

Please enter the name of the next youngest child

Child 2 Date of Birth

Please enter the date of birth of the child dd/mm/yy

Child 2 Gender

Please make a selection

Child 2 Ethnicity

Child 3 name

Please enter the name of the next youngest child

Child 3 Date of Birth

Please enter the date of birth of the child dd/mm/yy

Child 3 Gender

Please make a selection

Child 3 Ethnicity

Child 4 name

Please enter the name of the next youngest child

Child 4 Date of Birth

Please enter the date of birth of the child dd/mm/yy

Child 4 Gender

Please make a selection

Child 4 Ethnicity

Please list the details of any other children in the family

Please list the names and dates of birth of any other children in the family

Family Needs: identifying the areas in which Home-Start support can help

Please check all that apply1. Managing child’s behaviour2. Being involved in the child(ren)’s development3. Coping with own physical health4. Coping with own mental health5. Coping with feeling isolated6. Parents self-esteem7. Coping with child’s physical health8. Coping with child’s mental/emotional health9. Managing the household budget10. The day-to-day running of the house11. Stress caused by conflict in the family12. Coping with extra work caused by multiple birth/multiple children13. Use of services14. Other (please describe in the Other Needs box)

You may make multiple selections

Other Needs

Add any comments you wish to make.

Please explain why each apply*

Mandatory entry

Please tell us more about the support you feel the family need

optional

Early Help Assessment

Has an Early Help Assessment been completed for this family?*YesNo

Mandatory Entry

Please attach Early Help Assessment if one is available.

File type required is PDF, maximum size 3MB

Armed Forces Family

Armed Services Family?*YesNo

Mandatory Entry

Family Environment

Please tick all that apply to the familyLone ParentSubstance AbuseDomestic AbuseMental Health IssuesChild DisabilityPostnatal DepressionMultiple BirthParent Disability or IllnessHousingTransportAsylum SeekerRefugeeEnglish is a second languageTeenage Pregnancy - 19yrs or younger

Are there any other issues that we need to consider when placing a volunteer with this family? (e.g. domestic violence/pets/family history/drug/alcohol/hygiene/postnatal depression/mental health/smoking). Please add any comments you wish to make in the box below

Optional entry

Please add any background information that you think we would find useful

Marketing Feedback

How did you hear about Home-Start GuildfordSocial MediaWord of MouthExternal EventWebsiteGoogleFlyerPoster

Choose all that apply

Privacy Notice

Details of referrers are retained on our records as part of the processing of referral forms. Please indicate your acceptance of our privacy notice which can be found here Privacy Notice (opens in a new window).

Privacy Notice Accepted*

Please read our Privacy Notice before submitting the details you have provided to us

Downloadable Professional Referral Form

This form is available in two versions, one is PDF which will need to be printed and filled in assuming you do not have MS Word on your computer/ device, the other version is MS Word which can be edited and saved locally.

Downloadable Professional Referral Form (PDF) Downloadable Professional Referral Form (MS Word)

Self Referrals

How to make a Self Referral

Please click on the panel below called Online Self Referral Form. Fill in the form noting where there are mandatory entries. When you have completed the form click on the submit button at the bottom to send the form to us. If your application has been successful you will be taken to a “Thank you” page to confirm it has been submitted.

If you are unable to use the Online Self Referral Form, you can select the downloadable version.

Online Self Referral Form

Services

Which of our service(s) are you seeking?

Select the service required

Referral Date

Date*

Date of this referral

We may contact you from time to time to review and promote our service

Please confirm if you give consent to your contact details being held on our distribution list*I consentI do not consent

Mandatory entry

Home-Start Families are offered free events, such as visits or family picnics. Photos are taken to mark the event and for promotional use

Please confirm if you give consent for photos to be taken*I consentI do not consent

Mandatory entry

About your family

All items marked in red are required to submit the form.

Parent/ Main Carer Name*

Please enter name of Parent/Main Carer

Email Address*

Please enter a valid email address we can use to contact you

Date of Birth*

dd/mm/yy

Your Address*

Please enter your family's address here

Family's postal code*

Please enter your postal code.

Contact telephone number*

Please enter your contact number. It may help if this number can be used with WhatsApp

Parent/ Carer Ethnicity*

Emergency Contact Details:

An alternative contact to be used only in the event of an emergency whilst we are supporting you.

Emergency Contact Name

Optional entry

Emergency Contact Number

Optional entry

Relationship

Optional entry

Other Adults Living with the Child/ Children

Name of Partner

Please enter the name of your partner (if relevant)

Date of Birth

dd/mm/yy

Please select ethnicity

Please make a selection from the list

List any other adults living in the home

Please enter details of any other adults in household

Other Agencies

Does your family have any statutory agencies involved?*

Mandatory entry, answer yes or no.

If yes, please select all that apply

Children's Services

Select if applicable

Contact Name

Please enter the contact name

Contact number

Please enter a contact number

Intensive Support

Select if applicable

Contact Name

Please enter the contact name

Contact number

Please enter a contact number

Family Support Team

Select if applicable

Contact Name

Please enter the contact name

Contact number

Please enter a contact number

Family First Guildford (Family Centre)

Select if applicable

Contact Name

Please enter the contact name

Contact number

Please enter a contact number

Health Visitor

Select if applicable

Contact Name

Please enter the contact name

Contact number

Please enter a contact number

Parent Infant Mental Health

Select if applicable

Contact Name

Please enter the contact name

Contact number

Please enter a contact number

Perinatal Mental Health

Select if applicable

Contact Name

Please enter the contact name

Contact number

Please enter a contact number

Other

Select if applicable

Contact Name

Please enter the contact name

Agency Name

Please enter the name of the agency

Contact number

Please enter a contact number

Please enter the details below for the child/ children, starting with the youngest child

Child 1 name*

Please enter the name of the youngest child

Child 1 Date of Birth*

Please enter the date of birth of the child dd/mm/yy

Child 1 Gender*

Please make a selection

Child 1 Ethnicity*

Mandatory Entry

Child 2 name

Please enter the name of the next youngest child

Child 2 Date of Birth

Please enter the date of birth of the child dd/mm/yy

Child 2 Gender

Please make a selection

Child 2 Ethnicity

Child 3 name

Please enter the name of the next youngest child

Child 3 Date of Birth

Please enter the date of birth of the child dd/mm/yy

Child 3 Gender

Please make a selection

Child 3 Ethnicity

Child 4 name

Please enter the name of the next youngest child

Child 4 Date of Birth

Please enter the date of birth of the child dd/mm/yy

Child 4 Gender

Please make a selection

Child 4 Ethnicity

Please list the details of any other children in the family

Please list the names and dates of birth of any other children in the family

Family Needs: please identify all the areas you feel Home-Start support could help with

Please select all that apply1. Managing child’s behaviour2. Being involved in the child(ren)’s development3. Coping with own physical health4. Coping with own mental health5. Coping with feeling isolated6. Parents self-esteem7. Coping with child’s physical health8. Coping with child’s mental/emotional health9. Managing the household budget10. The day-to-day running of the house11. Stress caused by conflict in the family12. Coping with extra work caused by multiple birth/multiple children13. Use of services14. Other (please describe in the Other Needs box)

You may make multiple selections

Other Needs

Add any comments you wish to make.

Please tell us more about the support you feel you need

optional

Early Help Assessment

Has an Early Help Assessment been completed for your family?*YesNo

Mandatory Entry

Please attach Early Help Assessment if one is available.

File type required is PDF, maximum size 3MB

Armed Forces Family

Armed Services Family?*YesNo

Mandatory Entry

Family Environment

Please tick all that apply to your familyLone ParentSubstance AbuseDomestic AbuseMental Health IssuesChild DisabilityPostnatal DepressionMultiple BirthParent Disability or IllnessHousingTransportAsylum SeekerRefugeeEnglish is a second languageTeenage Pregnancy - 19yrs or younger

Marketing Feedback

How did you hear about Home-Start GuildfordSocial MediaWord of MouthExternal EventWebsiteGoogleFlyerPoster

Choose all that apply

Privacy Notice

Your details are retained on our records as part of the referral process. Please indicate your acceptance of our privacy notice which can be found here Privacy Notice (opens in a new window).

Privacy Notice Accepted*

Please read our Privacy Notice before submitting the details you have provided to us

Downloadable Self Referral Form

Downloadable Self Referral Form (PDF) Downloadable Self Referral Form (MS Word)

Next: Volunteering