Supervised Family Time Resident Referral

1Date preferences

2Children

3Adult with whom the child/ren lives

4CAFCASS, Contact Orders & Contact

5Arrival at the Child Contact Centre

6Information Relating to Safety of the Child

7Health & Medical Requirements

8Additional Information

9Details of person completing the form

What are your preferred dates and times?(Required)

Do you have a preferred method of contact?(Required)

How many sessions would you like to book?(Required)

Where did you hear about us?(Required)

If you selected the option 'Other', please tell us where:

Please select how many children are to be included in the referral(Required)

Child 1 First name(Required)

Child 1 Surname(Required)

Child 1 date of birth(Required)

DD slash MM slash YYYY

Child 1 gender(Required)

Child 2 First name(Required)

Child 2 Surname(Required)

Child 2 date of birth(Required)

DD slash MM slash YYYY

Child 2 gender(Required)

Child 3 First name(Required)

Child 3 Surname(Required)

Child 3 date of birth(Required)

DD slash MM slash YYYY

Child 3 gender(Required)

Child 4 First name(Required)

Child 4 Surname(Required)

Child 4 date of birth(Required)

DD slash MM slash YYYY

Child 4 gender(Required)

Child 5 First name(Required)

Child 5 Surname(Required)

Child 5 date of birth(Required)

DD slash MM slash YYYY

Child 5 gender(Required)

Adult first name(Required)

Adult last name(Required)

Adult relationship to child/ren(Required)

Parent/carer date of birth

Parent/carer ethnicity

Parent/carer religion

Adult address(Required)

Adult postcode(Required)

Adult phone(Required)

Please could you let us know the details of the other parent/person, if you have them?(Required)

Yes

Does this person have legal parental responsibility?(Required)

Yes

Child/ren ethnicity

Child/ren religion

Child/ren school name

Child school address

Name of the other parent

Address of the other parent

Postcode of the other parent

Email address of the other parent

Phone of the other parent

Do you have a solicitor?(Required)

Yes

Solicitor name(Required)

Solicitor reference(Required)

Name of practice(Required)

Solicitor address(Required)

Solicitor postcode(Required)

Solicitor email address(Required)

Solicitor phone(Required)

Is there an allocated CAFCASS officer?(Required)

Yes

Officer first name(Required)

Officer last name(Required)

CAFCASS address(Required)

CAFCASS postcode(Required)

CAFCASS phone(Required)

Where did Family time last take place?(Required)

Is there a Child Arrangement Programme in place?(Required)

Yes

When did Family time last take place?(Required)

DD slash MM slash YYYY

Please upload a copy of the Child Arrangement programme(Required)

Max. file size: 100 MB.

When is the next court date, if any?

DD slash MM slash YYYY

Have the family been involved with Mediation Services?(Required)

Yes

Please give details of mediation services(Required)

Is there or has there been any concerns relating to domestic abuse, drugs, alcohol or mental health?(Required)

Yes

Please give details of domestic abuse, drugs, alcohol or mental health(Required)

Are you prepared to meet the childrenâs father/mother?(Required)

Yes

Will the adult with whom the child(ren) reside be bringing them to and collecting them from the Centre? (please circle)(Required)

Yes

Who will be bringing/collecting the child(ren)?(Required)

What is the preferred date of first Family time contact at the Centre?(Required)

DD slash MM slash YYYY

How frequently will Family time take place?(Required)

For how long will each Family time last?(Required)

Are there or have there been sexual/child abuse allegations made in this family?(Required)

Yes

Please provide details of allegations(Required)

Is this family known to Social Services?(Required)

Yes

If known to Social Services, please provide details(Required)

Has any person who will be involved in the Family time ever been convicted of an offence against a child(ren)?(Required)

Yes

Please provide conviction details(Required)

Has there been, or is there likely to be, a risk of abduction?(Required)

Yes

Are there procedures in place for holding passports?

Yes

Please give details of any allegations, undertakings, injunctions or convictions relating to violence involving either party, their respective families or the children

Do any of the children have any illness, allergy, impairment, special needs or medical requirements?(Required)

Yes

Please provide details of any illness, allergy, impairment, special needs or medical requirements(Required)

Do any of the adults involved suffer from long-term physical/mental illness or an impairment?(Required)

Yes

Please provide details of long-term physical/mental illness or an impairment?(Required)

What language is spoken at home?(Required)

Is an interpreter required?(Required)

Yes

Please give details of the interpreter to be used (include name and organisation, if any)(Required)

Has this family ever used another Family time Centre?(Required)

Yes

Please give details of the centre used(Required)

Additional background information

Your first name(Required)

Your last name(Required)

Your email address(Required)

Your phone number(Required)

Your relationship to the child/ren(Required)

Supervised Resident Referral Form