Issuu on Google+

REFERRAL FORM FOR SUPERVISED CONTACT IN PUBLIC LAW CASES Wherever possible this form needs to be seen and completed by both parties’ solicitors any other professionals involved with the family Contact cannot commence until this form has been completed in full and received by the centre Co-ordinator. All information will be treated in the strictest confidence.

Office Use Only

Referral received Date of Pre-visit Date of first contact Dates Reviewed Contact Ended

1. Referrer Name:

Profession:

Address:

Postcode: Telephone: 2. Child (ren)

Name (s)

Date of Birth

Boy = B, Girl = G

Ethnicity

Legal Status


3. Details of where child(ren) reside Name: Relationship to child(ren): Ethnicity: Address:

Post code:

Telephone:

4a. Details of adults attending contact Name: Relationship to child(ren) Does this person have legal parental responsibility? (please circle) Yes No Length of time since: a) They met children b) They lived with children Address:

Post code: Telephone: Solicitor’s name:

Solicitor’s ref:

Name of practice: Address:

Post code:

Telephone:

4b. Details of adults attending contact Name: Relationship to child(ren) Ethnicity: Does this person have legal parental responsibility? (please circle) Yes

No

Length of time since: a) They met children b) They lived with children Address:

Post code:

Telephone:


Solicitor’s name:

Solicitor’s ref:

Name of practice: Address:

Post code:

Telephone:

5. LEGAL REPRESENTATIVE, CAFCASS, Contact Orders & Contact a) Is there an allocated CAFCASS Officer? (please circle) Yes If “Yes”, please give details: Name:

No

Name of CAFCASS Office: Address: Postcode:

Telephone No:

Fax Number: Email address of parties’ Legal Representative: b) When and where did contact last take place? c) Is there a court order relating to the contact? Yes No If “Yes”, please either send a copy or indicate what it specifies: d) What other court orders have been made in relation to the child(ren) and when? e) What is the next court date (if any)? 6. Details of Transport and Contact Details a) Name, designation and contact details of person(s) who will be bringing the child(ren) to the centre: Name: Workplace Address: Telephone Number: Mobile Number: b) What is the preferred date of first contact at the Centre? c) How frequently will contact take place? For how long will each visit last and preferred times?


e) Name(s) of other people allowed to participate in contact at the Centre Name

Relationship to Child (ren)

7. Statutory or Voluntary services involved with the family at present or in the past Name: Address: Telephone number: Fax number: Email address: b)The nature of any involvement with any of the statutory or voluntary services in the past or present: 8. Information Relating to Safety of the Child a) Are there or have there been sexual/child abuse allegations made in this family? (please circle). If “Yes”, please give details (over page) Yes

No

b) Has any person who will be involved in the contact been convicted of an offence against a child(ren)? (Please circle). Yes No If “Yes”, please give details: c) Has there been or is there likely to be a risk of abduction? (please circle) Yes No If “Yes”, are procedures in place for holding passports, etc (please circle) Yes No d) Please give details of any allegations, undertakings, injunctions or convictions relating to violence involving either party, their respective families or the child(ren)

9. Health & Medical Requirements a) Do any of the children have any illness, allergy, disability, special needs or medical requirements? (please circle) Yes No


If “Yes”, please give details: 10. Why is supervision required: What specifically needs observation/intervention? Name, designation and contact details of person(s) who will be bringing the child(ren) to the Centre 11. Level of Supervision Required. Please tick: a) Constant supervision. Supervisor remains in sight and sound of child)ren) throughout the meeting. � b) Moderate supervision. Supervisor does not need to remain in sight and sound of child(ren) at all times � c) How many supervisors are required? 12a. Are supervised outings permissible? (please circle) Yes No 12b. Are unsupervised outings permissible? (please circle) Yes No 13. Are the adults permitted to bring food and drink to the meeting? (please circle) Yes No 14. Are the adults permitted to pass written information and gifts to the child(ren)? (please circle) Yes No 15. Additional Information: a) What is the first language of the adults and children involved? 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? (please circle) Yes No How long? If “Yes”, please give details (this Centre may be contacted) d) Proposals for contact in the future?

e) Additional background information (please use a separate sheet if necessary)

This form has been completed accurately and to the best of my knowledge. Signed by: ………………….…………………………….. Date: ………………


RISK ASSESSMENT Risk assessment form must be completed in full before contact can commence Please complete the checklist below, filling each box with either a x or √ Please ensure that all √’s are fully detailed in the Risk Assessment form. Please indicate which of the following have affected or are continuing to affect the family you are referring and what is the current level of risk: Safeguarding children Yes/No/Allegations High Low None Physical Abuse Sexual Abuse: Emotional Abuse: Neglect: Risk of Abduction: Other potential concerns Domestic abuse: Conflict between adults: Alcohol abuse: Drug/substance abuse: Mental health issues: Cultural issues: Religious issues: Immigration / asylum: Financial issues: Medical conditions adult/child: Physical impairments adult/child: Parenting skills Involvement of other family members in the contact: Risk of violence towards staff: Risk of self harm: Other (please specify):


Risk Assessment Form must be completed in full before contact can commence Hazard Identified

Person(s) at Risk

Severity (1-16)

Existing Controls

Severity 1 High 16 Low Probability 1 Low 5 High The Risk Assessment has been completed accurately and to the best of my knowledge. Signed by ……………………………………. Date………………………….. Please return this form to address below: Maypole Family Support Ltd

46 Harrow Road, Wembley, HA9 6PL Tel: 07956208580 Email: maypoleservices@yahoo.com

Probability

Risk Rating

Remedial Action Required

Residual risk


Maypole family support services refferal form public law