Make a Referral - First Steps Surrey Child Contact Centre

- Step 1 of 12

Both 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. Children

Child's Name

First

Last

Date of Birth//

Further Children

If 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)

Are you the Non-resident parent? (children do not live with you)

Are you a 3rd party referrer (ie CAFCASS, social worker, solicitor)

If yes, please give details below.

2. 3rd Party Referrer (if you are not a parent/carer applying for Contact)

Name

First

Last

Profession

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Phone

3. Type of Contact Required

Type of Contact (please tick)

Supervised Contact
Supported Contact
Handover
Indirect Contact
Virtual Contact
Community Contact
Life Story/identity Contact
Room Hire
McKenzie Friend

Who will be paying for Contact?

4. Non-resident Parent / Adult requesting Contact

Name

First

Last

Date of Birth //

Relationship to Children

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Phone

Name of Solicitor (if applicable)

Solicitor’s reference

Name of Practice

Solicitor's Phone

Solicitor's Email

5. Adult with whom the child(ren) reside

Name

First

Last

Date of Birth//

Relationship to Children

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Phone

Name of Solicitor (if applicable)

Solicitor’s reference

Name of Practice

Solicitor's Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Solicitor's Phone

Solicitor's Email

6. CAFCASS, Contact Orders & Contact

a. Is there an allocated CAFCASS officer?

If ‘Yes’, please give details of name

First

Last

Name of CAFCASS office

Address of CAFCASS office

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

b. When and where did Contact last take place?

c. Are there any Child Arrangements / Court Orders in place?

If '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 below

d. Can the child(ren) be taken out of the Centre?

e. 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?

If 'Yes', please specify

7. Arrival at the Child Contact Centre

a. Are the parents willing to meet?

If ‘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?

If ‘No’, who will be bringing / collecting the child(ren)?

c. What is the preferred date of first Contact at the Centre?

//Date

Time

d. 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 Centre

g. Relationship to child(ren)

8. Information Relating to Safety of the Child

a. Are there or have there been sexual / child abuse allegations made in this family? (please tick).

If 'Yes', please give details below

b. Is this family known to Social Services?

If 'Yes', please give details below

c. Has any person involved in Contact ever been convicted of an offence against a child(ren)?

If 'Yes', please give details below

d. Has there been or is there likely to be a risk of abduction?

If '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.

9. Health & Medical Requirements

a. Do any of the children have any illness, allergy, impairment, special needs or medical requirements?

If ‘Yes’, please give details below

b. Do any of the adults involved suffer from long-term physical / mental illness or an impairment?

If ‘Yes’, please give details below

10. Additional Information

a. What language is spoken at home?

b. Is an interpreter required?

If ‘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)

If ‘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.org

e. Where did you hear about us?

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