Referral Form | Purple Elephant

Family Time / Contact Referral Form

If you are completing this form on behalf of someone else, please provide your name, email address, contact number and relationship to the person requiring contact.

About the person requiring Family Time / Contact:

Name

Address

Phone

Relationship to the children

Do you have any disabilities, health or other support needs?

What service do you require:

Please read the following before completing the table below.

Supported Contact

Supported contact helps to keep children in touch with parents if trust has broken down or communication is difficult. Parents do not have to meet. This is a form of contact where the level of risk is assessed to be lower than might be the case for supervised contact. It is also used to progress from supervised contact. In supported contact, direct observations are not made, and reports are not written. Staff will be present to ensure the comfort of those engaging in the service.

Supervised Contact

Is there a potential risk of harm? The centre ensures the physical safety and emotional well-being of children in a one-to-one observed setting. This form of contact is provided where it is assessed that there might be a higher risk or greater complexity in a family’s circumstance. These sessions will be supervised by staff who are experienced in this role. Observations will be made, and reports will be written. It is generally expected that staff will remain within sight and sound of children at all times.

Please tick all that apply. We do not facilitate handovers at the current time.

Why is the service needed:

If you have ticked any of the above please provide additional information.

Has the court ordered this contact?

About the Children:

Child/ren's current carer details

Child 1

Date of Birth

Gender

Ethnicity

Child 2

Date of Birth

Gender

Ethnicity

Child 3

Date of Birth

Gender

Ethnicity

Child 4

Date of Birth

Gender

Ethnicity

Please provide details of additional children including their name, D.O.B, Gender and ethnicity.

Please let us know if your child/ren have any health needs, additional needs or disabilities.

How does the child/ren feel about contact, and what has done to prepare them?

Additional Information:

If an interpreter required for the family, please state the languages spoken

Which professionals need to be sent a copy of the contact recordings

Solicitor

Social Worker

Please provide their name, telephone number and email address.

Please check the box to confirm both parties are aware of and are in agreement with the referral

Please check the box to confirm you give your consent for us to liaise with professionals

Please check the box to confirm the information included in this referral is accurate and truthful