Families creating

brighter futures

Referral number:

Sandwell’s Family Group Conference and Mediation Referral Form and Report

Universal / Universal Plus / Targeted Additional Needs / Complex/Significant Needs
Child(ren’s) Names
Date(s) of Birth
Ethnicity
Child’s Address
Name(s) address(es) and telephone numbers of adults with parental responsibility
First language
Any special needs/disability or communication needs
Siblings names and addresses (if different from child’s)
Legal status (Care Order, Sec 20 etc)
Any important dates
(ICPC, RCPC, core group, CIN meeting, Court dates)
As far as you are aware, are there extended family members
Have you discussed this referral with the family and are they in agreement with a FGC? / Yes No
Yes No
Name of School/nursery/Children’s Centre the Child attend?
Do you agree to attend the FGC to provide information to enable the family to create a plan?
Is your line manager aware of this referral? / Yes No
Yes No
Are there any safety or health risks the FGC should be aware of?
Is alcohol/drugs an issue?
Is Domestic Abuse an issue?
Is the child a young carer?
Is mental health an issue? / Yes No
Yes No
If yes please give details
Yes No
If yes are the concerns: current or past
Yes No
If yes please give details
Yes No
If yes please give details
Referrer contact details:
Location & team
Direct Phone line,
mobile number &
working hours

Please note:

  • Engaging in a Family Group Conference is voluntary and a family’s refusal should not be used as evidence of failure to cooperate.
  • The referrer needs to attend the whole Family Group Conference and review. These may occur outside of normal working hours or at weekends.
  • Please feel free to discuss any prospective referral with the FGC coordinator, Andrea Underhill

Report for Family Group Conference

This is for the family (not the FGC service). It will be taken out to all family members including the children of the family. Please keep it short and simple so that a seven year old could understand it! Please use signs of safety language 

Brief family History
This needs to be very short! We can look on ICS and will have an exchange meeting with you to get further details. This is for the family not us!
Please don’t use any professional jargon
What is going well for the family?(Please include: existing strengths and existing safety)
Please bullet point what is going well and what this means for the child/children
Please include exceptions to the worries.
Think about protective factors, coping strategies and resilience!
What is the child/children good at? What are their hobbies?
As referrer, what are your concerns/worries?(Please include: Harm, Danger statements and Complicating factors)
What are the worries and what is the impact or likely impact on the children?
Example We are worried that there is hitting, hurting and controlling from Dad to Mum. We say this because the police have been called to keep Mum and the children safe.
Research tells us that children who have seen hitting and hurting may get hurt themselves by trying to protect one parent. We are worried that this may happen to ……. and ……….
We also know that Children may see one of their parents as frightening and one as frighten when there is hitting and hurting. This is scary for children and may stop them from going to their parents when they don’t feel safe.
We are concerned because we say this because
Please include a Danger statement – what we are worried will happen if nothing is done!
What needs to happen?
List the questions you are asking the family to consider and answer at their FGC, to enable them to address the concerns(Please include : safety goals and next steps)
These are the questions that the family will be asked at the FGC!
Examples:
Who is there in the family who can support?
What support can they offer?
How can the family make each of the worries that Children’s Social Care have smaller or disappear?
How will……..spend time with Mum?
What will the families’ safety plan be if there is any more hitting, hurting and controlling?
Bottom line requirements
What is the Non Negotiable and absolutely cannot happen or absolutely has to happen? Legally what is in place or what will be in place?
What would happen if the worries stayed the same or got bigger? Would a judge need to decide what should happen next?

Signs of safety score at time of referral

010

Please include a signs of safety score here…..0 is most risk, 10 is least!

Agreement
This information on this form needs to be shared with the child/young persons, parent/carer/persons with PR and they need to sign to give their consent for the referral to be made.
We (young person, parents/carers/persons with PR) agree for this referral to be made and for relevant information to be shared with our extended family and relevant professionals
Child/young persons signature / Date:
Parent/Carer signature / Date:
Referrers signature / Date:

Please return this form to:

Andrea Underhill

Family Group Conference Coordinator

Family Group Conference and Mediation service

Specialist Services

Sandwell Council House

Oldbury

West Midlands

B69 3DE

What happens next?

The referral with be looked at within 48hours and a confirmation of receipt will be sent to the referrer.The referral will then be allocated and the allocated convener will contact you as soon as they possibly can. We aim to convene conferences within 6 weeks of the referral date where ever possible and in some cases much quicker than this. If you have any queries in the meantime, Please contact Andrea Underhill at or call on 0121 569 8595/ 07969447327

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OFFICE USE ONLY

Referral received on: / Allocated on: / Allocated to: