Anchor Supervised Contact Referral form
Please complete all sections of this form
Child/rens details
Rows
Forename
Surname
DOB
Gender/ Identifies as (pronoun)
1
2
3
Child/rens details
Rows
Ethnicity
Religion
Language
1
2
3
Home Address Including Postcode
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parents/carer details
Rows
Relationship
Name
Contact Number
Language
1
2
Payment ( details of who will be paying)
Rows
Relationship
Name
Email address to send invoice to
Full payment/split?
1
2
Communication: Any Special Communication Needs?
Rows
Yes/No
If yes please provide details:
1
Registered/Statutory Status
Rows
Y/N
Date/s
Please give details of name of child/young person, dates, category (if known)
Any child/ren in the family open to the local authority?
Any court orders in place?
Any current criminal proceedings?
Any child in the family has a disability?
History of Current Situation/Reason for Supervised Contact being Required
History of Current Situation/Reason for Supervised Contact being Required
Supervised Contact Details ** Please note that anyone not on the list below will not be permitted to join in the contact session.
Rows
Name of Person Attending Contact
Relationship to Child
Start and Finish Time
Day/s of Contact
Contact Number
1
2
3
4
Frequency of contact (please specify, weekly, monthly, one off etc.)
Frequency of contact (please specify, weekly, monthly, one off etc.)
Contact Location
Rows
Y/N
Please give details
Can contact take place in the community?
Is there a proposed meeting place? Please provide address.
Are there any areas/locations to be avoided during contact?
Is transportation (of the child) required either to or from contact or both?
Authorisations and Restrictions in Contact
Rows
Y/N
Please give details
Can photographs be taken during contact?
Can video recordings be made during contact?
Can gifts or money be exchanged during the sessions?
Can the child have communication with any other parties during contact (for example, speaking to a Grandparent on the phone)?
Rows
Y/N
High
Medium
Low
Other
If other please Describe what you require
Risk Assessment - Child
Rows
Y/N
If YES, please provide details e.g. whether this is current or historical
If YES, how would you like this to be managed by the contact supervisor?
Does the young person/child(ren) have any medical or related condition which may require intervention during contact?
Does the young person/child(ren) have any known allergies that may require intervention, or avoidance measures to be taken?
Risk Assessment - Adult/s
Rows
Y/N
If YES, please provide details e.g. whether this is current or historical
If YES, how would you like this to be managed by the contact supervisor?
Does any adult attending contact have a medical condition which may require assistance during contact?
Do the adult(s) attending require any special assistance to participate in contact? E.g. mobility issues.
Does any adult attending contact have issues of alcohol, solvent, or other substance misuse?
Does any adult pose a risk of child abduction?
Has any adult attending contact ever displayed sexualised behaviour towards children or adults?
Has any adult attending contact ever displayed physical abuse or emotional abuse to children?
Has any adult attending contact ever displayed physical threats or violence towards a professional?
Has any adult attending contact ever displayed verbal or racist abuse towards a professional?
Is any adult attending contact engaging in, or have a history of, criminal activity?
Are there any other risks that may be posed by the adult attending contact that the contact supervisor need to be aware of?
Please sign below to confirm the following
Both parties are aware of and in agreement with the referral.
The information included in this referral is accurate and truthful.
Full Name:
Signature:
Date of referral:
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Anchor contact & mediation services Ltd. Registered in England and Wales No: 16944716
Registered office address: Suite A, Church Walk House, Church Walk, Great Oaks, Basildon, SS14 1GJ
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