Please fill in all sections 1-9:

Referral Form

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

If ‘Yes’, please send a copy
If ‘Yes’, please send a copy

6. Arrival at the Child Contact Centre

If ‘Yes’, please send a copy
Under no circumstances will the Centre accept unaccompanied children for contact
If ‘Yes’, please send a copy
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
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.

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

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.

8. Health & Medical Requirements

9. Additional Information

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