Please Complete All Relevant Sections

/ FAMILY GROUP CONFERENCING REFERRAL FORM

PLEASE COMPLETE ALL RELEVANT SECTIONS

Date of Enquiry:

Allocation Date:

Referrer details:
Name:
Role:
Location:
email:
tel: ext: / Line Manager:
Email:
Telephone:
Other Agencies involved: e.g. School, Health Visitor
Name, role, workplace, contact details etc.
Name of young person(s) / Gender / Where living? Which School? / Ethnicity / D.O.B
Family’s first language:
Any special needs or considerations:
Names, Addresses and Telephone Numbers of Parents/Carers, Extended Family,significant others.
Name / Relationship to Young Person / Address, postcode & phone no.

Reason for referring to FGC service to support with following: markwith ‘x’ one box only

LAC child / Interim Care Order (ICO)
Part of Pre-proceedings / Twin Track Care planning
Section 20 / Section 17 CIN plan
CP plan / Planning to close the case
Part of Viability Assessment / Alternative Care / SGO Support
REOC – prevent accommodation / If any other, pls specify
Purpose of FGC
Briefly outline the reasons for your involvement and your role with the child and/or family member.
Purpose of the FGC (mark with ‘x’ as many as applicable)
Part of Viability Assessment / Finding Alternative Care for child/ren
Preventing significant harm / Addressing parents using drugs and alcohol abuse
Rehabilitating to families/extended families / Facilitating contact to safeguard
Addressing offending behaviour / Improving School Attendance
Establishing and maintaining contact / Improving Parental Capacity
Prioritising child/ren’s welfare to promote safeguard / Working with families DV issues
Addressing parental mental health issues / Part of the assessment
Any other please specify:-
What are your departments concerns?
What are the strengths of the family?
What other decision making processes are currently being used (CP, Legal, LAC)? Please give dates for next meetings.
What assessments are under way and when will they be completed?
Is there anything that would be considered unsafe or unacceptable in the family plan?(bottom lines)
What questions would you like the family meeting to address (to be negotiated)?
What support will the department offer to the family to consider including in their plan?
Do the family agree to a coordinator contacting them? Yes No
All information on this form needs to be shared with everyone involved in the FGC process. Do you give your consent for that to happen? Yes No

RISK ASSESSMENT FORM

Is it safe to visit the family?

FAMILY NAME:
ADDRESS
Is there FWI risk assessment for any members of the extended family?
Is there a history of physical assault, verbal aggression by family members on other family members?
Is there a history of physical assault, verbal aggression by family members on welfare staff?
Is it safe to visit family members alone in the home?
Is there any current drug use?
Have they got any dogs, snakes or any other dangerous pet?
Any violent criminal convictions?

For DV case only; what restrictions are in place, pls specify;

Does the victim recognise the domestic abuse? Yes No Y

Does the victim recognises the impact on the children and want to involve family / friends to improve the situation? Yes No

Does the perpetrator recognise the domestic abuse? Yes No

Does the perpetrator recognise the impact on the children and want to involve family / friends to improve the situation? Yes No

Do the extended family express any concerns about the safety of holding this meeting? Yes No

Is it safe and beneficial to have FGC for this family? Yes No