Make a referral by filling in the form below Or you can download a hard copy here.Download our information for referrers leaflet here Service(s) Requested * Please Indicate which of the following you require (all services carry a £50 referral fee): Indirect Contact (letters/ gifts/ e-mails) £25 per item (+ postage) Supervised Contact (to include a written observation report) £100.00 per hour Home Visit £80-£100 Supported Contact (no report included) £80 per hour Virtual Supervised Contact £50.00 per hour Handover Service £40.00 Please explain why you feel this referral is required and what you hope to achieve. * Name * First Name Last Name DOB: MM DD YYYY Email * Relationship to Child(ren): * Telephone Number: * (###) ### #### Can the adult that the child(ren) live with, know the contact details of the adult requesting contact? * Yes No Solicitor Information (of Residing Adult): Please add Solicitor's details here: Adult Requesting Services: Name * First Name Last Name Relationship to Child(ren): Address Address 1 Address 2 City State/Province Zip/Postal Code Country Telephone Number: (###) ### #### Email Can the adult requesting contact be given contact details relating to the adult with whom the children live? Yes No Solicitor Information (of Adult requesting service): Additional Requirements Do any of the children/ adults have any special needs or requirements? These may relate to illness, impairment, allergies, special educational needs, learning difficulties needs - or any other (please specify). Adult Child Will an interpreter be required? If so please detail language and who will provide and pay for interpreter. Adult Child Court Proceedings Please specify any Orders that are currently in place. e.g. care, residence, contact, parental responsibility, specific issues, prohibited steps, injunctions. Date of next court hearing: MM DD YYYY Finding of Fact Hearing/ Previous Convictions Please give full details of any offences, convictions or Findings of Fact involving children, domestic abuse, sexual offences, drugs, arson and firearms. Please include any relevant dates and the person(s) to whom these relate. Local Authority Involvement: Does one or more local authority Children’s Services Departments know the family? Name of authority and name of worker: Child(ren) involved: Dates of involvement: Nature of involvement: Are they subject to CP/CIN Plan? Any other Additional Information: Thank you!
