Impact Family Services - Child Contact Centre Referral Form

Type of contact required: Supervised ƒ Supported ƒ

Child Contact Centre Venue (for supported contact only): Sunderland ƒ South Shields ƒ Durham ƒ Middlesbrough ƒ Hartlepool ƒ Ashington ƒ Alnwick ƒ Berwick ƒ

Parties must attend a 30 minute initial assessment meeting before a decision is made as to whether a place can be offered at the contact centre.

Please send completed referrals to: IMPACT Family Services, In the Garden of St Luke’s Church, Maxwell Street, Pallion, Sunderland. SR4 6SF or email mary.hind@impactfs.co.uk

1. Referrer

Name:

Profession:

Address:

Postcode:

Telephone:

2. Child(ren)

Name(s)

Date of birth

Boy = B, Girl = G

3. Adult with whom the child(ren) reside

Date of birth

Country of Origin

Name:

Relationship to child(ren):

Address:

Postcode:

Telephone:

Solicitor's name:

Solicitor's ref:

Name of practice:

Address:

Postcode:

Telephone:

4. Adult requesting contact

Name:

Date of birth

Country of Origin

Relationship to child(ren):

Does this person have legal parental responsibility? (please circle)

Yes

length of time since:

a) They met children

b) They lived with children

Address:

Postcode:

Telephone:

Solicitor's name:

Solicitor's ref:

Name of practice:

Address:

Postcode:

Telephone:

5. CAFCASS, Contact Orders & Contact

a. Is there an allocated CAFCASS officer? (please circle)

Yes

If 'Yes', please give details: Name:

Name of CAFCASS office:

Address:

Postcode:

Telephone:

b. When and where did contact last take place?

c. Is there a court order relating to the contact? If 'Yes', please either send a copy or indicate what it specifies:

Yes

d. What other court orders or reports have been made in relation to the child(ren) and when? Please note: Any court orders relating to contact must accompany this referral form. You may need to request permission from the court to disclose this information to us.

e. If there is no contact order, have the parents agreed that the child can be taken out of the Centre?

Yes / No

f. What is the next court date (if any)?

6. Arrival at the Child Contact Centre
a. Are the parents willing to meet? (please circle)			Yes	No
b. Will the adult with whom the child(ren) reside be bringing them to and collecting them from the Centre?			Yes	No
If 'No', who will be bringing / collecting the child(ren)?

d. How frequently will contact take place?		Weekly	Fortnightly

f. Name(s) of other people allowed to participate in contact at the Centre:
Name(s)	Relationship to Child(ren


7. Information Relating to Safety of the Child
a. Are there or have there been sexual/child abuse allegations made in this family? If 'Yes', please provide details in section 9d			Yes		No
b. Is this family known to Social Services? If 'Yes', please provide details in section 9d			Yes		No
c. Has any person who will be involved in the contact ever been convicted of an offence against a child(ren)?			Yes		No
If 'Yes', please give details
d. Has there been or is there likely to be a risk of abduction If 'Yes', are procedures in place for holding passports, etc?			Yes		No
e. Please give details of any allegations, undertakings, injunctions or convictions relating to violence involving either party, their respective families or the children.
8. Health & Medical Requirements
a. Do any of the children have any illness, allergy, disability, special needs or medical requirements? If 'Yes', please give details			Yes		No

b. Do any of the adults involved suffer from long-term physical/mental illness or a disability? If 'Yes', please give details			Yes		No

9. Additional Information
a. What language is spoken at home?
b. Is an interpreter required? (please circle)	Yes	No
If 'Yes' please give details of the interpreter to be used (include name and organisation if any)

c. Has this family ever used another Child Contact Centre? If 'Yes', please give details (this Centre may be contacted).	Yes	No




d. Additional background information (Please use a separate sheet if necessary).

This form has been completed accurately and to the best of my knowledge.

Signed: .

Date: ..

N.B. Only dates and times of family’s attendance will be disclosed unless it is felt that anyone using the Child Contact Centre or a volunteer/staff member is at risk of harm.

PLEASE NOTE THAT FROM APRIL 2012 ALL PARENTS / CARERS WILL BE GHARGED FOR USING OUR SUPPORTED CHILD CONTACT CENTRES