Family Time Services Referral Form

Family Time Services Referral Form

Any information provided will be treated in the strictest confidence. Please ensure all sections are completed and to the best of your knowledge.
Instructions
Person Completing this Form
Full Name*

First NameLast Name
Role*

ParentSolicitorCAFCASSNYASSocial WorkerAdvocateOther
Name of Company or Agency
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Email Address*
example@example.com
Telephone Number*
Please enter a valid phone number.Format: 00000 000000.
Signature*
Date*

DayMonthYear
Date
Details of Professionals Involved (Current)
Professional 1 - Full Name

First NameLast Name
Professional 1 - Role

ParentSolicitorCAFCASSNYASSocial WorkerAdvocateOther
Professional 1 - Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Professional 1 - Email Address
example@example.com
Professional 1 - Telephone Number
Please enter a valid phone number.Format: 00000 000000.
Professional 2 - Full Name

First NameLast Name
Professional 2 - Role

ParentSolicitorCAFCASSNYASSocial WorkerAdvocateOther
Professional 2 - Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Professional 2 - Email Address
example@example.com
Professional 2 - Telephone Number
Please enter a valid phone number.Format: 00000 000000.
Which Centre do you Wish to Attend?*

Chatham - 18 New Road Avenue, ME4 6BADartford - Banks Place, DA1 1EX
Details of Services Required*

Supported Family Time (no reports)Supported Handover (no reports)Supervised Family Time with Summary Report (not suitable if in court proceedings)Supervised Family Time with Detailed ReportContact AssessmentVirtual Family Time (please notify if room & equipment required)Indirect Family Time (letterbox, gifts etc.)
Please provide a full account as to why the service is required, including any allegations and why family time has broken down. Referrals will not be accepted if this section is incomplete.*
Have Social Services been involved with the family attending the Centre? Either currently or historically.*

YesNo
If yes, please provide information as to why they have been involved, the name and contact details of the social worker.
When did the children last spend time with the contact parent? Please provide rough dates, details of attendance to other Contact Centres, and details of any incidents or concerns.*
Is this family subject to any Child Contact Arrangements or Fact Finding Hearings?*

YesNo
If yes, please provide any Court Orders that relate to family time or are relevant to services such as prohibited steps, non-molestation and fact finding hearings.

Cancelof
Are CAFCASS or NYAS involved?*

YesNo
If yes, please provide any safeguarding letters or Section.7 reports that may have been completed.

Cancelof
CAFCASS or NYAS Worker Name

First NameLast Name
CAFCASS or NYAS Worker Phone Number
Please enter a valid phone number.Format: 00000 000000.
CAFCASS or NYAS Worker Email Address
example@example.com
Booking Requirements
Preferred Weekday Session Times

MondayTuesdayWednesdayThursdayFriday10.00 - 12.0012.30 - 14.3016.00 - 18.00
Preferred Weekend Session Times - Fortnightly Only

Saturday (Fortnightly Only)Sunday (Fortnightly Only)09.00 - 11.0011.30 - 13.3014.30 - 16.30
Preferred Frequency*

WeeklyFortnightlyFour-weeklyOther
Details of Children Attending
Children Attending*
Does any child attending have any additional needs? Include any disabilities, diagnosis or assessments of needs.
Any other information regarding the child(ren) that the Centre should be aware of:
Details of Resident Parent/Adult
Resident Parent/Adult - Name(s)*

First NameLast Name
Resident Parent/Adult - Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Resident Parent/Adult - Telephone No.*
Please enter a valid phone number.Format: 00000 000000.
Resident Parent/Adult - Email Address*
example@example.com
Resident Parent/Adult - Relationship*
Resident Parent/Adult - Date of Birth*

DayMonthYear
Date
Resident Parent/Adult - First Language*
Resident Parent/Adult - Ethnicity*
Does the Resident Parent/Adult have any additional needs?
Does the Resident Parent/Adult have Parental Responsibility?*

YesNo
Details of Contact Parent/Adult
Contact Parent/Adult - Name(s)*

First NameLast Name
Contact Parent/Adult - Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Contact Parent/Adult - Telephone No.*
Please enter a valid phone number.Format: (000) 000-0000.
Contact Parent/Adult - Email Address*
example@example.com
Contact Parent/Adult - Relationship*
Contact Parent/Adult - Date of Birth*

DayMonthYear
Date
Contact Parent/Adult - First Language*
Contact Parent/Adult - Ethnicity*
Does the Contact Parent/Adult have any additional needs?
Does the Contact Parent/Adult have Parental Responsibility?*

YesNo
Is an interpreter required?*

YesNo
If yes, provide details of organisation used and their contact details or ask us for support.
Details of Other Agreed Attendees
Other Agreed Attendees
Risk Assessment
Does the referred person or any other person attending the Centre pose any risk to themselves or others? (Staff, other families, children)*

YesNo
If yes, please provide details.
Have the Police ever been involved with anyone attending the Centre? Please give details of involvement and any convictions, arrests, cautions, convictions, and custodial sentences.*

YesNo
If yes, please provide details.
Are there any potential risks in the interaction between children and others in the contact sessions? (Inappropriate language, negative comments about plans, incitement of negative behaviour)*

YesNo
If yes, please provide details.
Are there any specific issues not noted above? (Health concerns etc.)*

YesNo
If yes, please provide details.

Please indicate which of the following have affected or are continuing to affect the family you are referring. Please provide details, don’t just mark yes.*

Rows	Yes	Details
Physical Abuse
Sexual Abuse
Emotional Abuse
Stalking & Harassment
Neglect
Risk of Abduction
Domestic Abuse
Coercive Behaviour
Conflict Between Adults
Alcohol Abuse
Substance Misuse
Mental Health Issues
Immigration/Asylum
Parenting Skills
Violence
Self-Harm
Other

How did you hear about us?
Persons Responsible for Payment
Payment Responsible Parties
Preferred way to pay the referral fee*

Cash/Card (at the Centre)Payment Link
If you are unsure if the other party are going to engage with the referral then please ONLY PAY the making contact fee of £30.00. This fee is not available where a court has ordered contact to take place.
Acknowledgement and Agreement
1. The referral fee and making contact fee is non-refundable.
2. Failure to make payment for the services as specified within our payment terms (three days in advance) may result in the suspension of services and/or withheld reports.
3. Cancellation fees are as follows, the paying party is liable for these fees:
  - Within 24 hours – 100% of the costs
  - Up to 48 hours – 50% of the costs;
4. Foundations: Supporting Families (FSF) will continue booking sessions until we are told otherwise, therefore please notify us, in writing, if services are no longer required. Failure to do so will incur charges;
5. A deposit for the first session will be requested on completion of the referral process;
6. Payment links are only provided for the referral fee and deposit. After this, all payments are to be received by cash or card at the Centre.
7. FSF reserve the right to withdraw services at any time;
8. Reports will be sent to both parents/adults, via email within 7 working days of sessions taking place, as well as any professionals involved in contact such as solicitors, CAFCASS or Social Services.
Name (Referrer)*

First NameLast Name
Signature (Referrer)*
Date (Referrer)*

DayMonthYear
Date
Should be Empty:

Family Time Services Referral Form

Person Completing this Form

Details of Professionals Involved (Current)

Booking Requirements

Details of Children Attending

Details of Resident Parent/Adult

Details of Contact Parent/Adult

Details of Other Agreed Attendees

Risk Assessment

Persons Responsible for Payment

Acknowledgement and Agreement