Local Authority Referrals - Supervised Contact Services

Referrer details

Name of Referrer

Organisation (if applicable)

Role/Relationship to Child(ren)

Address

Telephone

Refer more than 1 individualRefer up to 4 individuals at once by selecting in the drop down.

Child/ Children's details (1)

Full name

Date of birth

Day

Month

Year

Gender/Identifies as (pronoun)

Self describe:

Current address

School/Nursery (if applicable)

Any additional needs (health, SEND, disability)

Parent/Carer/Family Details

Resident Parent/ Carer

Full name

Date of birth

Day

Month

Year

Address

Contact number

Email Address

Non-Resident Parent/Carer / Family Member

Full name

Date of birth

Day

Month

Year

Address

Contact number

Email Address

Contact Arrangements Requested

Type of contact (supervised, supported, handover, community-based, in-home if authorised)

Frequency requested (weekly, fortnightly, monthly, etc.)

Preferred length of sessions

Preferred venue(s)

Any restrictions (e.g. no unsupervised time, specific conditions of court order)

Court Orders / Safeguarding Information

Is there a current court order? (Yes/No) – if yes, attach copy

Upload file

No file chosen

Is Cafcass involved? (Yes/No) – if yes, provide details

Any safeguarding concerns known? (brief summary here – full details to go in risk assessment)

Child/ Children's details (2)

Full name

Date of birth

Day

Month

Year

Gender/Identifies as (pronoun)

Self describe:

Current address

School/Nursery (if applicable)

Any additional needs (health, SEND, disability)

Parent/Carer/Family Details

Resident Parent/ Carer

Full name

Date of birth

Day

Month

Year

Address

Contact number

Email Address

Non-Resident Parent/Carer / Family Member

Full name

Date of birth

Day

Month

Year

Address

Contact number

Email Address

Contact Arrangements Requested

Type of contact (supervised, supported, handover, community-based, in-home if authorised)

Frequency requested (weekly, fortnightly, monthly, etc.)

Preferred length of sessions

Preferred venue(s)

Any restrictions (e.g. no unsupervised time, specific conditions of court order)

Court Orders / Safeguarding Information

Is there a current court order? (Yes/No) – if yes, attach copy

Upload file

No file chosen

Is Cafcass involved? (Yes/No) – if yes, provide details

Any safeguarding concerns known? (brief summary here – full details to go in risk assessment)

Child/ Children's details (3)

Full name

Date of birth

Day

Month

Year

Gender/Identifies as (pronoun)

Self describe:

Current address

School/Nursery (if applicable)

Any additional needs (health, SEND, disability)

Parent/Carer/Family Details

Resident Parent/ Carer

Full name

Date of birth

Day

Month

Year

Address

Contact number

Email Address

Non-Resident Parent/Carer / Family Member

Full name

Date of birth

Day

Month

Year

Address

Contact number

Email Address

Contact Arrangements Requested

Type of contact (supervised, supported, handover, community-based, in-home if authorised)

Frequency requested (weekly, fortnightly, monthly, etc.)

Preferred length of sessions

Preferred venue(s)

Any restrictions (e.g. no unsupervised time, specific conditions of court order)

Court Orders / Safeguarding Information

Is there a current court order? (Yes/No) – if yes, attach copy

Upload file

No file chosen

Is Cafcass involved? (Yes/No) – if yes, provide details

Any safeguarding concerns known? (brief summary here – full details to go in risk assessment)

Child/ Children's details (4)

Full name

Date of birth

Day

Month

Year

Gender/Identifies as (pronoun)

Self describe:

Current address

School/Nursery (if applicable)

Any additional needs (health, SEND, disability)

Parent/Carer/Family Details

Resident Parent/ Carer

Full name

Date of birth

Day

Month

Year

Address

Contact number

Email Address

Non-Resident Parent/Carer / Family Member

Full name

Date of birth

Day

Month

Year

Address

Contact number

Email Address

Contact Arrangements Requested

Type of contact (supervised, supported, handover, community-based, in-home if authorised)

Frequency requested (weekly, fortnightly, monthly, etc.)

Preferred length of sessions

Preferred venue(s)

Any restrictions (e.g. no unsupervised time, specific conditions of court order)

Court Orders / Safeguarding Information

Is there a current court order? (Yes/No) – if yes, attach copy

Upload file

No file chosen

Is Cafcass involved? (Yes/No) – if yes, provide details

Any safeguarding concerns known? (brief summary here – full details to go in risk assessment)

Risk Assessment Form (1) (to be attached to each referral)

General Information

Name of child

Date of birth

Referrer name and organisation

Date of assessment

Identified Risks (tick all that apply & provide detail)

Domestic abuse (history / ongoing concerns)

Substance misuse (alcohol / drugs)

Mental health concerns

Criminal history (violence / sexual offences / other)

Child protection plan involvement (past/present)

Allegations against parent/family member

History of missed contact or non-compliance

Concerns about abduction / failure to return child

Other (please specify)

Protective Factors

Supportive extended family

Previous positive contact

Willingness to engage with services

Stable accommodation / lifestyle

Other (please specify)

Risk Management / Required Safeguards

Venue requirements (e.g. neutral location only)

Number of supervisors required

Restrictions (e.g. no alcohol use within 24 hours of session, no physical discipline, etc.)

Special measures (e.g. staggered arrival/departure times)

Other (please specify)

Additional Notes

Risk Assessment Form (2) (to be attached to each referral)

General Information

Name of child

Date of birth

Referrer name and organisation

Date of assessment

Identified Risks (tick all that apply & provide detail)

Domestic abuse (history / ongoing concerns)

Substance misuse (alcohol / drugs)

Mental health concerns

Criminal history (violence / sexual offences / other)

Child protection plan involvement (past/present)

Allegations against parent/family member

History of missed contact or non-compliance

Concerns about abduction / failure to return child

Other (please specify)

Protective Factors

Supportive extended family

Previous positive contact

Willingness to engage with services

Stable accommodation / lifestyle

Other (please specify)

Risk Management / Required Safeguards

Venue requirements (e.g. neutral location only)

Number of supervisors required

Restrictions (e.g. no alcohol use within 24 hours of session, no physical discipline, etc.)

Special measures (e.g. staggered arrival/departure times)

Other (please specify)

Additional Notes

Risk Assessment Form (3) (to be attached to each referral)

General Information

Name of child

Date of birth

Referrer name and organisation

Date of assessment

Identified Risks (tick all that apply & provide detail)

Domestic abuse (history / ongoing concerns)

Substance misuse (alcohol / drugs)

Mental health concerns

Criminal history (violence / sexual offences / other)

Child protection plan involvement (past/present)

Allegations against parent/family member

History of missed contact or non-compliance

Concerns about abduction / failure to return child

Other (please specify)

Protective Factors

Supportive extended family

Previous positive contact

Willingness to engage with services

Stable accommodation / lifestyle

Other (please specify)

Risk Management / Required Safeguards

Venue requirements (e.g. neutral location only)

Number of supervisors required

Restrictions (e.g. no alcohol use within 24 hours of session, no physical discipline, etc.)

Special measures (e.g. staggered arrival/departure times)

Other (please specify)

Additional Notes

Risk Assessment Form (4) (to be attached to each referral)

General Information

Name of child

Date of birth

Referrer name and organisation

Date of assessment

Identified Risks (tick all that apply & provide detail)

Domestic abuse (history / ongoing concerns)

Substance misuse (alcohol / drugs)

Mental health concerns

Criminal history (violence / sexual offences / other)

Child protection plan involvement (past/present)

Allegations against parent/family member

History of missed contact or non-compliance

Concerns about abduction / failure to return child

Other (please specify)

Protective Factors

Supportive extended family

Previous positive contact

Willingness to engage with services

Stable accommodation / lifestyle

Other (please specify)

Risk Management / Required Safeguards

Venue requirements (e.g. neutral location only)

Number of supervisors required

Restrictions (e.g. no alcohol use within 24 hours of session, no physical discipline, etc.)

Special measures (e.g. staggered arrival/departure times)

Other (please specify)

Additional Notes

Text

I confirm that all information provided is correct. *Yes