FAMILY GROUP CONFERENCE

REFERRAL FORM

Please complete all sections of this form

All Children/Young Persons Details Referred for FGC:
Name(s) of Children/YP being Referred: / LCS/EHM Number(s) / Date of Birth(s) / M/F / YP Tel no / Who has Parental Responsibility?
Who does Child/YP usually reside with?
Name:
Relationship to Child:
Address:
Postcode:
Telephone number:
Mothers contact details (if not above):
Father’s contact details (If not above): / Any other person living in the child’s household?
Name:
Relationship to Child:
Telephone number:
Wider Family/Friends/Adult Siblings to invite to FGC:
Full Name / Address / Tel No / Relationship to Child/ren?
Childs/Young Person’s Religion: Please state:
Child/Young Person’s Ethnicity (Please be specific):
Communication Needs (including language):
Does anyone have special communication needs and what are they?
Is an Interpreter needed and for whom?
What Language is needed?

Please attach a copy of Child Protection Plan Child in Need Plan, and any Child in Care Review actions with this referral if applicable.

Status of Child:Name of any child who is or has been on a Child Protection Plan?
Child 1
Child 2
Child 3 / Date of Registration:
Category of CP Plan:
Name of current CP Chair:
Name of any child that is or has been looked after by a Local Authority?
Child 1
Child 2
Child 3 / Date of accommodation:
Order:
Name of current IRO:
Name of any child in the family has a diagnosed or undiagnosed disability?
Child 1
Child 2 / Specify nature of disability:
Name of any party subject to current criminal proceedings?
Name: / Specify nature of criminal proceedings:
Risk Indicators & Hazards:Please record any issues which may present a risk to others i.e. address, violence, aggressive dogs, substance Misuse, Mental Ill Health, etc.
If yes, please give details:
Risk to Professionals Yes  No
Any other Professionals involved with the child:i.e. Health Visitor, School, Lead Professional for CAF, Mental Health Worker, Police Officer, Family Support Worker etc.
Professional/Agency / Name and Address / Tele No.
Is a CAF in place? Yes  No*If Yes please attach a copy of the CAF to this Referral*
Has a previous Family Group Conference (FGC) been completed?
Yes  No
Group Work: Would you like to make a referral?
Handling Teenager Behaviour  Positive Parenting  Caring Dads 
Is this child/YP at risk of coming into care?Yes  No 
Please give full details:
What is going well:
Relevant History/Concerns/Reason for FGC Referral:
What needs to happen/Change:
List of Questions to be addressed at the FGC:
Bottom Line:
Awareness of Referral:
I can confirm that I have made the child/young person and parents/carers aware of this referral.
The child / young person knows about the referral /  Yes
 No
The parent /carer knows about the referral & agrees to have an FGC /  Yes
 No
Referred by :
Name of Referrer:
Managers Name:
Team/Agency :
Date of Referral:
Address:
Email:
Mobile No:
Ext:

1

Please complete and return prior to the Exchange Meeting

Email:

Tel 020 8270 6968