PART A – THE REFERRAL FORM
Has a person with parental responsibility (PR) and the children consented to this FGC referral? If NO, then this referral cannot be accepted. / YES / NO
Dates for the FGC Coordinator to be aware of: Core Group, Court dates, Annual leave, etc.
Referrer’s Name: / Job Title:
Contact Telephone numbers, address and email: / Team:
Supervisor’s name and contact details: / Date referral started:
Details of all subject child(ren) / young person(s)
ID no. / Name / DOB / EDD / Gender / Disability / Address
Status of Child(ren): Please tick or put the child’s name if there is more than one child and they have different a status:
CIN / CP / CP & Pre-proceedings / PLO / Section 20 / LAC / LAC & Proceedings / Legal Order (please specify)
Date of Pre-proceedings (PLO) issued if applicable: / Date of Court Proceedings issued if applicable: / Date of Court Order (please specify if applicable):
Current living arrangements of the children: Please tick
With mother / With father / With both parents / With maternal extended family / With paternal extended family / With family friend / With neighbour / In foster care
Immediate Family / Household Composition and Significant Others:
Name: / Relationship to child(ren): / PR:
Yes / No / Address: / Telephone / mobile no. / Ethnicity:
Details for Family / Friends / Significant others:
Name: / Relationship to child(ren): / Address: / Telephone / mobile no.
The family’s first language: / Is an interpreter needed?
YES / NO / The family’s maternal cultural / religious practices? / The family’s paternal cultural / religious practices?
Has the family expressed a preference for the FGC’s Coordinator gender / ethnicity / language spoken? If so, what are they?
Please detail any information in respect to a child / young person / family member / friend / significant other who has a known disability:e.g. mobility, hearing loss, learning difficulty etc.
Brief summary of the background reasons for Family and Children’s Services involvement with the children and the focus of this referral: Concerns expressed by the referrer and other agencies will help formulate the Agenda for the FGC. Part B will be created with the assistance of the FGC Manager.
PART B – THE FGC AGENDA
Part B 1-7 will be shared with parents, family members and friends prior to and during the FGC
  1. What are Family and Children’s Services current concerns and how to they impact on the children?

  1. What needs to change and what are the proposed timescale for this?

  1. Based on the concerns above, what questions does the family network need to consider in order to make their Family Plan?

  1. List the strengths of the children, parents and family network:

  1. What resources will be available to support the young person / child(ren) and their family?

  1. Is there anything the family need to know that would not be acceptable to Family and Children’s Services to include in the Family Plan?

  1. What action would Family and Children’s Services take if the family cannot make a Family Plan, if concerns increase, or if no sustainable positive changes are made?

  1. Space provided so parents can offer their comments:

PART C – Other Important Information:
Risk assessment:Please state if whether there has been a history of domestic violence between the parents, or verbal or physical abuse aimed at a professional, or any other health and safety concern for the Independent FGC Coordinator to consider. If so, can you assist in completing a risk assessment:
Concerns expressed by family and friends:
Concerns expressed by child(ren) and young person(s):
Agencies involved with the child(ren) and young person(s): who might be approached to act as an advocate? Or is a referral needing to be sent to Children’s Advocacy Service?
Other agencies involved with the family: names & contact details:

If you would like to discuss this referral, please speak to the FGC Manager; TK Vincent by ringing: 02084 168869 or email:

TO BE COMPLETED BY FGC MANAGER:
Date received by:
FGC Coordinator allocated:
Date case allocated:
Referral number:

Family Group Conference Information Sharing Consent Form:

I give permission for the contents of the Family Group Conference Agenda to be shared with identified family members, social and professional network on a as needed basis to enable my FGC to be held. By signing this document I am not necessarily agreeing with the accuracy of its contents.

Signed:Dated:

Print Name:

Relationship to the child(ren):

Signed:Dated:

Print Name:

Relationship to the child(ren):

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