Resident parent referral form

About the person completing this form

Name *

Address *

Phone number

Email address *

Please input information about the affected children

Child #1

Name

Date of Birth

Age

Gender

Child #2

Name

Date of Birth

Age

Gender

Child #3

Name

Date of Birth

Age

Gender

Child #4

Name

Date of Birth

Age

Gender

Do any of the children named above have any disabilities, health, or additional support needs? Please also list allergies here.

Relationship

Please use this space to tell us about previous contact and when and why the relationship ended. *

Who has parental responsibility? *

If the children are old enough to understand and have a view, how do they feel about family time and what work has been done to prepare them?

Children’s feelings, views wishes and preferences

Work completed to prepare children for family time

Court proceedings

Has the court ordered this family time? *

Yes

No

Comment (If yes, please detail the nature of the court order, as well as the date it was made and the court who wrote this)

Child arrangements order

A child arrangements order (CAO) may determine where a child will live and with whom, and whether, how and when they will spend time with a parent or people including relatives other than those they normally live with.

If a child arrangements order is in place please include the details of the date the order was made and any notes regarding this.

Prohibited steps order

A prohibited steps order (PSO) is an order that forbids someone from exercising parental responsibility in a particular manner, e.g. forbidding a parent from: • removing the child from the UK; • changing the child’s name; or • changing the child’s school.

If a prohibited steps order is in place please include the details of the date the order was made and any notes regarding this.

Specific issues order

A specific issue order (SIO) is an order made by the family court where a dispute arises about a question of how parental responsibility is exercised.

If a specific issues order is in place please include the details of the date the order was made and any notes regarding this.

Non-molestation order

A non-molestation order (NMO) is typically issued to prohibit a person from using or threatening physical violence, intimidating, harassing, pestering, or communicating with the victim of these actions. An order could prevent the abuser coming within a certain distance of a person, or address. It could also include children in certain circumstances. An order will also prevent an abuser from instructing or encouraging others to do any of those actions.

If a non-molestation order is in place please include the details of the date the order was made and any notes regarding this.

Are there any other orders or convictions? (please include details below)

Are there any court proceedings in the family court? *

Yes

No

Comment (If yes, please detail the nature of the order, as well as the date it was made and the court who wrote this.)

Is it possible that any of the parties might initiate new proceedings in the family court? *

Yes

No

Comment (If yes, please detail the nature of the order, as well as the date it was made and the court who wrote this)

Details of any professionals working with the family

Name

Organisation

Telephone number

Email address

Nature of involvement

About the service required

Please read the following before completing the next table.

Supported family time

A supported contact centre provides supported family time to keep children in touch with the parent that they no longer live with, if trust has broken down or communication is difficult. Parents do not have to meet, and several families use the facilities at the same time.

This is a form of family time where the level of risk is assessed to be lower than might be the case for supervised family time. It is also used to progress from supervised family time.

In supported family time, direct observations are not made, and no reports are written. Staff or volunteers will be present to ensure the comfort of those engaging in the service.

Supervised family time

Is there a potential risk of harm? A supervised contact centre provides supervised family time, and ensures the physical safety and emotional well-being of children in a one-to-one observed setting.

This is a form of family time where the level of risk is assessed to be higher risk than might be the case for supported family time, or if a family’s circumstances are more complex. These sessions will be supervised by staff who are experienced in this role.

Other (Please provide information about any other risks in the space below.)

If you have ticked yes to any of the concerns listed above, please provide additional information.

Family time is usually a short-term arrangement. How do you feel about using this service? Do you have any ideas about how and / or when your family might be ready to move on from the service?

Will anyone else be coming with you when you bring your child/children to our Centre for family time? Please give their name and relationship to you below.

Is an interpreter required for your family? *

Yes

No

Languages spoken

Are you agreeable to the children’s father/mother taking photographs?

Yes

No

Agreement

1. I confirm the information included in this referral is accurate and truthful.
2. I have read and understood the Centre’s Privacy Policy as shown on the website:
https://wokingfamilycontactcentre.org.uk

If you agree to the above, please sign (or give your name) below and give today’s date.

Your Name *

Date *

About the person completing this form

Please input information about the affected children

Child #1

Child #2

Child #3

Child #4

Relationship

If the children are old enough to understand and have a view, how do they feel about family time and what work has been done to prepare them?

Court proceedings

Child arrangements order

Prohibited steps order

Specific issues order

Non-molestation order

Details of any professionals working with the family

About the service required

What support do you need from Woking Family Contact Centre?

Why is the service needed?

Physical abuse

Sexual abuse

Neglect

Emotional abuse

Domestic abuse

Drug misuse

Alcohol misuse

Abduction

Conflict

Mental health

Culture / Religion

Finance

Learning difficulties

Parenting capacity

Physical impairments

Wider family

Current crime

Convictions

Pets

Agreement

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