Make a referral by filling in the form below Or you can download a hard copy here.Download our information for referrers leaflet here Name * First Name Last Name Phone * (###) ### #### Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Relationship to family? * About the child(ren) requiring contact * Do any of the children listed above have any disabilities? * Yes No If yes, please add details here. Please also list any allergies Please use this space to tell us about previous contact and why this ended? How does the child(ren) feel about contact and what work has happened to prepare them? * About the adult requiring contact * First Name Last Name Phone * (###) ### #### Email Address * Address 1 Address 2 City State/Province Zip/Postal Code Country How is the adult related to the child. * Does this person have parental responsibility? * Yes No Does this Person have any Disabilities, Health, or Additional Support Needs? * Yes No If yes, please give us details How does this person feel about using the service for contact? * Has the court ordered this contact? * Yes No (If yes, please detail the nature of the order, as well as the date it was made and the Court who wrote this) Are there any Court Proceedings in the Family Court? * Yes No (If yes, please detail the nature of the order, as well as the date it was made and the Court who wrote this) Is it possible that any of the parties might initiate new Proceedings in the Family Court? * Yes No (If yes, please detail the nature of the order, as well as the date it was made and the Court who wrote this) About the service required * Please read the following before completing the table below. Supported contact helps to keep children in touch with parents if trust has broken down or communication is difficult. Parents do not have to meet, and several families use the facilities at the same time. This is a form of contact where the level of risk is assessed to be lower than might be the case for supervised contact. It is also used to progress from supervised contact. In supported contact, direct observations are not made, and reports are not written. Staff or volunteers will be present to ensure the comfort of those engaging in the service. Supervised Contact Is there a potential risk of harm? The centre ensures the physical safety and emotional well-being of children in a one-to-one observed setting. This form of contact is provided where it is assessed that there might be a higher risk or greater complexity in a family’s circumstance. These sessions will be supervised by staff who are experienced in this role. Observations will be made, and reports will be written. It is generally expected that staff will remain within sight and sound of children at all times. I have read the above I have not read the above Tick as appropriate * Supervised Contact Supported Contact Virtual Contact Indirect Contact Handover Service Comments Nature Of Concern * Please tick appropriate options Physical abuse Sexual Abuse Neglect Emotional Abuse Drug Misuse Alcohol Misuse Abduction Conflict Mental Health Culture / Region Finance Learning Difficulties Parenting Capacity Physical Impairments Wider Family Current Crime Convictions Pets Other (Please specify below) If you have ticked yes to any of the above please provide more details Risk - Please answer yes, no or allegations. Risk level - Please answer high, low or none. Contact is usually a short-term steppingstone. Please provide your perception of how and / or when this family might be ready to move on from the service * Is an interpreter required for this family? * Yes No Languages Spoken (As the referrer we will be asking you to organise the interpreter. This must be a reputable professional.) Please confirm the following * 1. Both parties are aware of and in agreement with the referral. 2. The information included in this referral is accurate and truthful. Digital Signature * Date of Referral * MM DD YYYY Thank you! We will be in touch as soon as possible.
