Private Referrals - Supervised Contact Services Essex

Private referral form

Section 1: Your Details (the person making the referral)

Name

Relationship to the Child(ren) (e.g. mum, dad, grandparent, carer)

Address

Phone

Email Address

Section 2: Child/Children’s Details

Name

Date of birth

Any medical conditions, special needs, or support needs

Section 3: Other Parent/Carer / Family Member Details

Full Name

Date of birth

Address (if known)

Phone (if known)

Email Address (if known)

Section 4: Contact Arrangements You’re Hoping For

(Please tell us what you’d like – we’ll talk it through with you before anything is agreed)

Type of contact (supervised session, supported contact, handover, etc.)

How often you’d like sessions (weekly, monthly, etc.)

How long you’d like them to last (1 hour, 2 hours, etc.)

Where you’d prefer sessions to happen (community venue, park, café, family home if suitable)

Section 5: Important Information We Need to Know

(This helps us make sure sessions are safe for your child – please be honest, there is no judgement.)

Are there any court orders we should be aware of? (attach copy if you have one)

No file chosen

Supporting information for court orders

Are there any concerns about safety (e.g. disagreements, past difficulties, or risks we should know about)?

Has Cafcass or social services been involved? (Yes/No, if yes, please give details)

Risk Information Form

(If you’re unsure how to complete this, we can help you by phone or email.)

Any concerns (tick or describe): arguments, conflict, mental health, substance use, previous police involvement, etc.

Things that help make sessions easier/safer (protective factors): supportive family members, history of good contact, willingness to work together, etc.

Anything specific you’d like us to do to make sessions easier for your child

I confirm that all information provided is correct. *Yes

Spicer’s

Spicer’s

Spicer’s

Private referral form

Section 1: Your Details (the person making the referral)

Section 2: Child/Children’s Details

Section 3: Other Parent/Carer / Family Member Details

Section 4: Contact Arrangements You’re Hoping For

(Please tell us what you’d like – we’ll talk it through with you before anything is agreed)

Section 5: Important Information We Need to Know

(This helps us make sure sessions are safe for your child – please be honest, there is no judgement.)

Risk Information Form

(If you’re unsure how to complete this, we can help you by phone or email.)