Bounce Back for Kids (BB4K)Referral FormReceived: ______

BB4K-A support programme for children affected by domestic abusethat raises children’s self-esteem and gives them an opportunity to explore and express their feelings through fun, child-focussed activities, in a safe therapeutic way.

YOUNG PERSON(S) CAUSING MOST CONCERN

Childs full name / DOB / Gender / Address and Post code / Contact number / Ethnic Origin

Has the programme been explained to the child/young person? YES/NO

Has s/he agreed to it? YES/NO

PARENT(S)/CARER(S) DETAILS

Parents/ Carers full name / (1) / (2)
Relationship to child
Gender
Ethnic origin
Address
(including postcode)
Is address permanent?
Contact numbers
Occupation

Has the programme been explained to parent/s or carer/s? YES/NO

Has s/he agreed to it? YES / NO

Other Family members

Names(s) / Relationship to child above / DOB / Gender / Address (if different from above) / Contact number / Ethnic Origin

FURTHER INFORMATION

Education – School name, address & telephone no.
What is the main concern regarding this child?
What does the child want to get out of this group?
Can child commit to a 10 week programme?
Has the perpetrator left family home? If yes, when did they leave. Please give
details about contact between child and perpetrator.
How is this child’s behaviour being managed at the moment? What tactics have been agreed and what works well?
How does this child relate in a group setting? i.e. class, playground
What other agencies are involved with the family?
Has other domestic abuse work being undertaken with family? E.g. Freedom / Recovery Toolkit
Please give details about safety concerns facilitator needs to be aware of when conducting home visit
Do you consider child able to cope with and benefit from working in a group? / Yes / No / Details:
Is the child’s level of spoken English adequate for working in such a group? / Yes / No / Details:
Any special learning needs? / Yes / No / Details:
Any physical disabilities/special needs? / Yes / No / Details:
Any further relevant information:
Referrer Name/Position/Agency / Address and Post Code / Contact phone number and e-mail
How long have you known/ worked with the family?
Date completed:

When completed, please return this form directly to the support worker/ centre that is delivering the BB4K programme orto PACT by email at:

If you would like to discuss this referral further please contact Ruth Boys, Community Senior Support Worker, on 07824 095975 / 0118 402 1755

© Parents And Children Together 2016