Supervised Family Time Non-Resident Referral

1Date preferences

2Details of the children

3Details of the adults

4Contact

5Solicitors, CAFCASS & Court Orders

6Information Relating to Safety of the Child

7Health & Medical Requirements

8Additional Information

9Payment and submission

What are your preferred dates and times?(Required)

Do you have a preferred method of contact?(Required)

How many sessions would you like to book?(Required)

You only pay the £60 administration fee when submitting this form. We will contact you for full payment if your application is successful.

What is the preferred date of the first Family time at the Centre?(Required)

DD slash MM slash YYYY

How frequently will Family time take place?(Required)

For how long will each Family time contact last?(Required)

Where did you hear about us?(Required)

If you selected the option 'Other', please tell us where:

Please select how many children are to be included in the referral(Required)

Child 1 first name(Required)

Child 1 surname(Required)

Child 1 date of birth(Required)

DD slash MM slash YYYY

Child 1 gender(Required)

Child 2 first name(Required)

Child 2 surname(Required)

Child 2 date of birth(Required)

DD slash MM slash YYYY

Child 2 gender(Required)

Child 3 first name(Required)

Child 3 surname(Required)

Child 3 date of birth(Required)

DD slash MM slash YYYY

Child 3 gender(Required)

Child 4 first name(Required)

Child 4 surname(Required)

Child 4 date of birth(Required)

DD slash MM slash YYYY

Child 4 gender(Required)

Child 5 first name(Required)

Child 5 surname(Required)

Child 5 date of birth(Required)

DD slash MM slash YYYY

Child 5 gender(Required)

Child/Children's religion

Child/Children's ethnicity

Child/Children's school name and address

When did you last meet your child/children?(Required)

DD slash MM slash YYYY

When did you last live with your child/children?(Required)

DD slash MM slash YYYY

Adult first name(Required)

Adult last name(Required)

Adult relationship to child/ren(Required)

Adult date of birth

DD slash MM slash YYYY

Adult ethnicity

Adult religion

Adult address(Required)

Adult postcode(Required)

Adult phone(Required)

Please could you let us know the details of the other adult/parent, if you have them?(Required)

Yes

Does the other adult/parent have legal parental responsibility?(Required)

Yes

Name of the other adult

Address of the other adult

Postcode of the other adult

Email address of the other adult

Phone number of the other adult

Are you prepared to meet the other adult/parent?(Required)

Yes

Why did contact break down?(Required)

When did Family Time last take place?(Required)

DD slash MM slash YYYY

Where did Family Time last take place?(Required)

Do you have a Solicitor?(Required)

Yes

Solicitor name(Required)

Solicitor reference

Name of practice(Required)

Solicitor address(Required)

Solicitor postcode(Required)

Solicitor email address(Required)

Solicitor phone(Required)

Is there an allocated CAFCASS officer?(Required)

Yes

Cafcass Officer first name(Required)

Cafcass Officer last name(Required)

CAFCASS address(Required)

CAFCASS postcode(Required)

CAFCASS phone(Required)

Is there a Child Arrangement Programme in place?(Required)

Yes

Please upload a copy of the Child Arrangement programme(Required)

Max. file size: 100 MB.

When is the next court date, if any?

DD slash MM slash YYYY

Have your family been involved with Mediation Services?(Required)

Yes

Please give details of mediation services(Required)

Is there or has there been any concerns relating to domestic abuse, drugs, alcohol or mental health?(Required)

Yes

Please give details of domestic abuse, drugs, alcohol or mental health(Required)

Are there or have there been sexual/child abuse allegations made in the family?(Required)

Yes

Please provide details of allegations(Required)

Is your family known to Social Services?(Required)

Yes

If known to Social Services, please provide details(Required)

Has any person who will be involved in the Family Time ever been convicted of an offence against a child(ren)?(Required)

Yes

Please provide conviction details(Required)

Please give details of any allegations, undertakings, injunctions or convictions relating to violence involving either party, their respective families or the children

Do any of the children have any illness, allergy, impairment, special needs or medical requirements?(Required)

Yes

Please provide details of any illness, allergy, impairment, special needs or medical requirements(Required)

Do any of the adults involved suffer from long-term physical/mental illness or an impairment?(Required)

Yes

Please provide details of long-term physical/mental illness or an impairment?(Required)

What language is spoken at home?(Required)

Is an interpreter required?(Required)

Yes

Please give details of the interpreter to be used (include name and organisation, if any)(Required)

Have you or your family ever used another Family time Centre?(Required)

Yes

Please give details of the centre used(Required)

Additional background information

Your first name(Required)

Your last name(Required)

Your email address(Required)

Your phone number(Required)

You agree to pay a £63 non-refundable administration fee.

I agree and I will pay now

We will contact you after processing your form to process payment for your selected service, providing your form is approved.

Form submission(Required)

Price:

Total

Date

DD slash MM slash YYYY

Supervised Non-Resident Referral Form