Professionals

First name

Last name

Phone

Email

Organisation

Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Relation to the person(s) you are referring

What are your preferred dates and times?

How many sessions would you like to book?

3

6

9

Other

How many sessions would you like to book?

How did you hear about us?

How did you hear about us (other)?

How many children are to be included in this referral?

Child 1 first name

Child 1 last name

Child 1 date of birth

Child 1 gender

Child 2 first name

Child 2 last name

Child 2 date of birth

Child 2 gender

Child 3 first name

Child 3 last name

Child 3 date of birth

Child 3 gender

Child 4 first name

Child 4 last name

Child 4 date of birth

Child 4 gender

Child 5 first name

Child 5 last name

Child 5 date of birth

Child 5 gender

Adult first name

Adult last name

Relationship to child/ren

Does this person have legal parental responsibility?

Adult address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Adult phone number

When did they last meet the child/ren?

When did they last live with the child/ren?

Child/ren ethnicity

Child/ren religion

Child/ren school name

Child/ren school address

Why did contact break down?

Is there an allocated CAFCASS officer?

Officer first name

Officer last name

CAFCASS address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

CAFCASS phone

Where did Family Time last take place?

When did Family Time last take place?

Is there a Child Arrangement Programme in place?

Please upload a copy of the Child Arrangement Programme

Max. file size: 10 MB.

When is the next court date (if any)?

Have the family been involved with Mediation Services?

Please give details of Mediation Services

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

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

Are they prepared to meet the children's father/mother?

Will the adult with whom the child/ren reside bne bringing them to and collecting them from the Centre?

Who will be bringing/collecting the child/ren?

What is the preferred date of first Family Time at the Centre?

How frequently will Family Time take place?

For how long will each Family Time last?

Are there or have there been sexual/child abuse allegations made in this family?

Please provide details of allegations

Is this family known to Social Services?

If known to Social Services, please provide details

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

Please provide conviction details

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?

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

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

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

What language is spoken at home?

Is an interpreter required?

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

Has this family ever used another Family Time Centre?

Please give details of the centre used

Additional background information

Professional referrals