Private & Confidential
Specialist Assessment and Treatment Services
Enquiry Form - ASSESSMENT
Please email your completed form to .We aim to respond to your enquiry with costings and timescales within 5 working days of receipt of this form.
Case Name: / Date of Enquiry:ADULTS INVOLVED
Name: / Relationship to child: / Ethnicity: / Location: / To be assessed?
Yes
Yes
Yes
Yes
CHILDREN / YOUNG PERSONS INVOLVED
Name: / Gender: / Age: / Ethnicity: / Current Placement: / To be assessed?
Yes
Yes
Yes
Yes
ADDITIONAL INFORMATION
Do any of the adults and/or children have additional requirements?(such as an interpreter or accessible facilities)
Yes Please give details (including names)
Do any of the parties live more than 1 hour’s travel from the Centre?
Yes Please indicate whether the parties (and professionals) are willing to travel to the Centre for appointments
Does referral concern contact issues between separated parents?
Yes Please note that we require a joint Letter of Instruction agreed by all parties in order proceed with the referral.
REFERRER DETAILS
Referrer Name: / Organisation: / Tel:
Job Title: / Address: / Email address:
REFERRAL INFORMATION
Case Background:
Professional Concerns:
Aim of Assessment:
Date of next hearing:
Expected date of instruction:
Deadline for filing the report:
FUNDING
How will the work be funded:
Legal Aid Agency: / Local Authority: / Privately: / Other:
If fees are split between the parties please provide details:
We collect and process information about users of our services.All data is kept securely in compliance with the Data Protection Act 1998 at all times. We will not give this information to anyone without relevant consent,unless exceptional circumstances where the law allows.
You can read more about this on our website
Our Patron: Her Royal Highness The Duchess of Cambridge
The Anna Freud National Centre for Children and Families is a company limited by guarantee, company number 03819888, and a registered charity, number 1077106.