Impactchild Contact Centre Referral Form

ImpactChild Contact Centre Referral Form

SUPPORTED CHILD CONTACT

Please note: Both parties are required to attend a separate initial assessment meeting to ensure supported contact is suitable before a decision is made as to whether a place can be offered at the contact centre.

Please send completed referrals to:

IMPACT Family Services,35 West Sunniside, Sunderland SR1 1BU or email

Referral Fee: The person making this referral is required to pay a referral fee of £10

1. Referrer:
Nameof person requesting contact:
Address:
Postcode: / Telephone:
Do you have legal parental responsibility? / Yes No
Do you have a solicitor? (if yes please give details)
Does the other party know that you have made a referral to the Child Contact Centre? / Yes / No
2. Child(ren)
Name(s) / Date of birth / Boy = B, Girl = G
3. OTHER PARTY - Who the Child(ren) live with?
Name:
Relationship to child(ren):
Address:
Postcode: / Telephone No:
Email Address
When and where did you last have contact with the child(ren).
Is there a court order relating to the contact? / Yes / No
If 'Yes', please either send a copy or indicate what it specifies.
If there are any court orders or reports made in relation to the child(ren) Please forward copies. / Yes / No
Are there any court dates arranged?
Name(s) of other people wishing participate in contact at the Centre: / Relationship to Child(ren) - (Grandparent / sibling / Aunt / Uncle)
7. Information Relating to Safety of the Child(ren)
Have there been sexual/child abuse allegations made? / Yes / No
If 'Yes', please give details:
Is this family known to Children’s Social Services? / Yes / No
If 'Yes', please give details:
Has any person who will be involved in the contact ever been convicted of an offence against a child(ren)? / Yes / No
If 'Yes', please give details:
Has there been or is there likely to be a risk of abduction? / Yes / No
If 'Yes', please give details:
Please give details of any allegations, undertakings, injunctions or convictions relating to violence involving either party, their respective families or the children.
8. Health & Medical Requirements
a. Do any of the children have any illness, allergy, disability, special needs or medical requirements? If 'Yes', please give details / Yes / No
b. Do any of the adults involved suffer from long-term physical/mental illness or a disability? If 'Yes', please give details / Yes / No
9. Additional Information
What language is spoken at home?
Is an interpreter required? (please circle) / Yes / No
If 'Yes' please give details of the interpreter to be used (include name and organisation if any)
Has you ever used another Child Contact Centre? If 'Yes', please give details (this Centre may be contacted). / Yes / No
Additional background information (Please use a separate sheet if necessary).

This form has been completed accurately and to the best of my knowledge.

Signed: .

Date: ..

N.B. Only dates and times of family’s attendance will bedisclosed unless it is felt that anyone using the Child Contact Centre or a volunteer/staff member is at risk of harm.

Contact Centre Fees: £10 Referral - Session Fee per adult: £10 if employed £5 if Unemployed

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