Self-Referral Form and Agreement for Contact

Who has parental resposibility for the children *

If Other please state

When did the relationship end *

Day

Month

Year

Why did the relationship end *

When did the other parent last see the children *

Day

Month

Year

When did the other parent last live with the children *

Have any of the family ever been known to or involved with any of the following organisations

CAFCAS

Social Services

The Courts

Mediation Services

Are there any concerns relating to domestic violence *

Are there any mental health issues? *

Yes

No

Mental health issues

Are there any concerns relating to Drugs or/and Alcohol *

If yes to either question please give further information

Does any parent have any convictions *

If yes please give details

When did contact last take place

Day

Month

Year

Where did contact last take place

Who was involved with the contact

Why did the contact breakdown/end

how do the children feel about having contact

Prefered contact time *

How long would you like the contact session *

1 Hour

2 Hours

Contact service required *

Would you wish anybody else to be involved in the contact (if the other parent agrees) *

Deatils of third party attendance request

Are both parents currently in contact

Will staggered arrival / departure be required *

Would you wish to take the children out of the centre (if the other parent agrees) *

Has this been agreed with the resident parent *

Do any of the children have any health and medical requirements? *

What language is spoken at home *

Will an interpreter be needed *

Who will be paying for the interpreter (please be aware that this will not be covered by Children North East) *

Are there any issues you feel the centre needs to be aware of *

I confirm that the information contained within this form is to the best of my knowledge both accurate and true *

I agree to abide by the rules and conditions of the Centre if I am offered a place *

I understand that the centre reserves the right to either refuse or terminate contact if I have withheld any information or behave in a way that breaks the centres rules or conditions *

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