Referral

Please state which centre

Knock

Newtownards

Bangor

1. Children

Name

Age

DOB

Boy or Girl?

Boy

Girl

Name

Age

DOB

Boy or Girl?

Boy

Girl

Name

Age

DOB

Boy or Girl?

Boy

Girl

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2. Adult requesting contact

Name

Email

Relationship to child(ren):

Does this person have legal parental responsibility?

Yes

No

Length of time since they met children

Length of time since they lived with children

Address

Postcode

Telephone

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Your Solicitor’s Information

Solicitor’s name

Solicitor’s Email

Name of practice

Solicitor’s ref:

Solicitor’s Address

Solicitor’s Postcode

Solicitor’s Telephone

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Name

Email

Relationship to child(ren):

Address

Postcode

Telephone

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Their Solicitor’s Information

Solicitor’s name

Solicitor’s Email

Name of practice

Solicitor’s ref:

Solicitor’s Address

Solicitor’s Postcode

Solicitor’s Telephone

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4. Referrer

Name

Email

Profession

Address

Postcode

Telephone

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a. Is there an allocated Court Welfare Officer / Social Worker?

Yes

No

If ‘Yes’, please give details - Name, Address, Telephone Number:

b. When and where did contact last take place?

c. Is there a court order relating to the contact?

Yes

No

If ‘Yes’, please send a copy

d. Have any other court orders been made in relation to the child(ren)?

Yes

No

If ‘Yes’, please send a copy

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

Yes

No

f. What is the next court date (if any)?

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6. Arrival at the Child Contact Centre

a. Are the parents willing to meet?

Yes

No

b. Will the adult with whom the child(ren) reside be bringing them to and collecting them from the Centre?

Yes

No

If ‘Yes’, please send a copy

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

Under no circumstances will the Centre accept unaccompanied children for contact

c. Is there any reason why presents cannot be given to the children?

Yes

No

If ‘Yes’, please send a copy

d. Does any court order exist restricting the taking of photographs

Yes

No

Photographs can be taken of the child(ren) in line with our photographic policy (attached) unless a court order prohibits this. Videos/recordings are not permitted

e. What is the preferred date of first contact at the Centre?

Contact will commence at earliest two weeks after receipt of a completed referral form as pre-visit appointments must be attended prior to contact starting.

f. How frequently will contact take place?

g. For how long will each visit last?

h. Names / Relationship to child(ren) of other people allowed to participate in contact at the Centre:

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

Yes

No

If ‘Yes’, please give details:

b. Does this family have any current involvement with Social Services?

Yes

No

If ‘Yes’, please give details:

c. Has any person who will be involved in the contact ever been convicted of an offence against a child / children?

Yes

No

If ‘Yes’, please give details:

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

Yes

No

If ‘Yes’, are procedures in place for holding passports, etc?

Yes

No

e. Has any person who will be involved in the contact ever been convicted of any criminal offence?

Yes

No

If ‘Yes’, please give details:

f. Are there any other details of any allegations, undertakings, injunctions relating to violence against anyone?

Yes

No

The coordinator will assess the suitability of a referral subject to a risk assessment. Please note that failure to disclose any information pertaining to these matters will result in a referral not being accepted, or contact being stopped.

If ‘Yes’, please give details:

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

Yes

No

If ‘Yes’, please give details:

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

Yes

No

If ‘Yes’, please give details:

c. Do any of the adults involved suffer from any drug / alcohol addictions?

Yes

No

If ‘Yes’, please give details:

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a. What language is spoken at home?

b. If an interpreter is required, please advise the centre of the arrangements

Include name and organisation

c. Has this family ever used another Child Contact Centre?

Yes

No

If ‘Yes’, please give details:

Please note that failure to disclose this information will result in a referral not being accepted, or contact being stopped.

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d. Additional background information

reCAPTCHA

1. Children

2. Adult requesting contact

Your Solicitor’s Information

3. Adult with whom the child(ren) reside

Their Solicitor’s Information

4. Referrer

5. Court Welfare Officer/Social Worker, Contact Orders & Contact

6. Arrival at the Child Contact Centre

7. Information Relating to Safety of the Child & Contact Centre

8. Health & Medical Requirements

9. Additional Information