Please enable JavaScript in your browser to complete this form. - Step 1 of 12Both parents and professionals can make a Referral using this form which must be completed in full. All details will be dealt with in strict confidence unless authorised to release, or in the event of safeguarding issues involving children or vulnerable adults. Please note there is a registration fee of £50 which includes a pre-assessment at the Centre.1. ChildrenChild's NameFirstLastDate of BirthDD12345678910111213141516171819202122232425262728293031/MM123456789101112/YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Further ChildrenIf there is more than one child in your application, please enter them in the box above (one per line) including their date of birth.Are you the Resident parent? (children live with you)YesNoAre you the Non-resident parent? (children do not live with you)YesNoAre you a 3rd party referrer (ie CAFCASS, social worker, solicitor)YesNoIf yes, please give details below.Next2. 3rd Party Referrer (if you are not a parent/carer applying for Contact)NameFirstLastProfessionAddressAddress Line 1Address Line 2CityState / Province / RegionPostal CodePhoneEmailPreviousNext3. Type of Contact RequiredType of Contact (please tick)Supervised ContactSupported ContactHandoverIndirect ContactVirtual ContactCommunity ContactLife Story/identity ContactRoom HireMcKenzie FriendWho will be paying for Contact?PreviousNext4. Non-resident Parent / Adult requesting ContactNameFirstLastDate of Birth DD12345678910111213141516171819202122232425262728293031/MM123456789101112/YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Relationship to Children Address Address Line 1Address Line 2CityState / Province / RegionPostal CodePhone Email Name of Solicitor (if applicable)Solicitor’s referenceName of Practice Solicitor's PhoneSolicitor's EmailPreviousNext5. Adult with whom the child(ren) resideName FirstLastDate of BirthDD12345678910111213141516171819202122232425262728293031/MM123456789101112/YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Relationship to ChildrenAddress Address Line 1Address Line 2CityState / Province / RegionPostal CodePhone Email Name of Solicitor (if applicable) Solicitor’s referenceName of PracticeSolicitor's AddressAddress Line 1Address Line 2CityState / Province / RegionPostal CodeSolicitor's PhoneSolicitor's EmailPreviousNext6. CAFCASS, Contact Orders & Contacta. Is there an allocated CAFCASS officer? YesNoIf ‘Yes’, please give details of nameFirstLastName of CAFCASS officeAddress of CAFCASS officeAddress Line 1Address Line 2CityState / Province / RegionPostal Codeb. When and where did Contact last take place?c. Are there any Child Arrangements / Court Orders in place? YesNoIf 'Yes', please upload any Child Arrangements / Court Orders below Click or drag files to this area to upload. You can upload up to 6 files. If 'Yes', please specify any Child Arrangements belowd. Can the child(ren) be taken out of the Centre? YesNoe. What is the next court date (if any)?f. Do either of the parent’s contact details need to remain undisclosed from the other parent? YesNoIf 'Yes', please specifyPreviousNext7. Arrival at the Child Contact Centrea. Are the parents willing to meet? YesNoIf ‘No’ , what arrival/departure measures are to be put in place?b. Will the adult with whom the child(ren) reside be bringing them to and from Centre? YesNoIf ‘No’, who will be bringing / collecting the child(ren)?c. What is the preferred date of first Contact at the Centre?DD12345678910111213141516171819202122232425262728293031/MM123456789101112/YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920DateTimed. How frequently will Contact take place?e. For how long will each visit last?f. Names of other people allowed to participate in Contact at the Centreg. Relationship to child(ren)PreviousNext8. Information Relating to Safety of the Childa. Are there or have there been sexual / child abuse allegations made in this family? (please tick).YesNoIf 'Yes', please give details belowb. Is this family known to Social Services?YesNoIf 'Yes', please give details below c. Has any person involved in Contact ever been convicted of an offence against a child(ren)? YesNoIf 'Yes', please give details belowd. Has there been or is there likely to be a risk of abduction? YesNoIf 'Yes', please give details below, including any procedures in place for holding passports, etc.e. Please give details of any allegations, undertakings, injunctions or convictions relating to violence involving either party, their respective families or the children.PreviousNext9. Health & Medical Requirementsa. Do any of the children have any illness, allergy, impairment, special needs or medical requirements?YesNoIf ‘Yes’, please give details belowb. Do any of the adults involved suffer from long-term physical / mental illness or an impairment? YesNoIf ‘Yes’, please give details belowPreviousNext10. Additional Informationa. What language is spoken at home?b. Is an interpreter required? YesNoIf ‘Yes’, please give details of the interpreter to be used (include name and organisation if any)c. Has this family ever used another Child Contact Centre? (please circle)YesNoIf ‘Yes, please give details (this Centre may be contacted)d. Additional background information.If there is any additional relevant information, please email or send any documents to contact@surreycontactcentre.orge. Where did you hear about us?PreviousNextPreviousPreview my SubmissionUpdating preview…This is a preview of your submission. It has not been submitted yet! Please take a moment to verify your information. You can also go back to make changes.PreviousSubmit