Please advise who will be responsible for the cost of contact services:

Please explain why you feel this referral is required and what you hope to achieve

(Please include the last date that the children and non-resident parent had contact)

Child(ren’s) Details:

Please include Names, Age & DOBs, Genders, Ethnicitys, Who they are living with and who has PR.

Non -Resident Parent/Carer

Relationship to Child(ren)

Email

Solicitor's Details

Non- Resident Parent

Relationship to Children

Email

Solicitor's Details

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.

Court Proceedings:

Please specify any Orders that are currently in place.

e.g. care, residence, contact, parental responsibility, specific issues, prohibited steps, injunctions.

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.

Local Authority/ CAFCASS Involvement:

(please provide contact details)

Name of authority and name of Social Worker:

Nature of involvement:

Are they subject to CP/CIN Plan?

Name of CACASS worker

Frequency of Contact

(preferences will be considered but cannot be guaranteed due to contact service availability)

How often will family time take place?

How many family time sessions are required?

Please provide preferred days (Mon, Tues, Wed, Sat, Sun)

Please provide preferred times (9am – 6pm)

£50 Referral Fee

Payable for all services upon submission via bank transfer: NON-REFUNDABLE Connected Families CIC Sort Code: 309950 Account number 47756062

Location

Hours

Contact