FORM-PKS Supervised Contact Referral - Please complete all sections of this form

Please complete all sections of this form

Please confirm this is the form you require PKS SUPERVISED CONTACT REFERRAL or close this tab to return to the form selection screen.

Please provide details of all children/young people being referred

Child /Young person Local Authority ID Number

Child /Young person Gender/Identifies as (pronoun)

Child /Young person Forename

Child /Young person Ethnicity

Child /Young person Surname

Child /Young person Religion

Child /Young person Date of birth

Child /Young person Language

2nd child /young person being referred

2nd Child /Young person Local Authority ID Number

2nd Child /Young person Gender/Identifies as (pronoun)

2nd Child /Young person Forename

2nd Child /Young person Ethnicity

2nd Child /Young person Surname

2nd Child /Young person Religion

2nd Child /Young person Date of birth

2nd Child /Young person Language

3rd child /young person being referred

3rd Child /Young person Local Authority ID Number

3rd Child /Young person Gender/Identifies as (pronoun)

3rd Child /Young person Forename

3rd Child /Young person Ethnicity

3rd Child /Young person Surname

3rd Child /Young person Religion

3rd Child /Young person Date of birth

3rd Child /Young person Language

4th child /young person being referred

4th Child /Young person Local Authority ID Number

4th Child /Young person Gender/Identifies as (pronoun)

4th Child /Young person Forename

4th Child /Young person Ethnicity

4th Child /Young person Surname

4th Child /Young person Religion

4th Child /Young person Date of birth

4th Child /Young person Language

Home Address Including Postcode

Address Including Postcode

Parents/carers Details

Parents/carers Relationship

Parents/carers Gender/Identifies as (pronoun)

Parents/carers Name

Parents/carers Ethnicity

Parents/carers Contact Number

Parents/carers Language

2nd Parents/carers details

2nd Parents/carers Relationship

2nd Parents/carers Gender/Identifies as (pronoun)

2nd Parents/carers Name

2nd Parents/carers Ethnicity

2nd Parents/carers Contact Number

2nd Parents/carers Language

3rd Parents/carers details

3rd Parents/carers Relationship

3rd Parents/carers Gender/Identifies as (pronoun)

3rd Parents/carers Name

3rd Parents/carers Ethnicity

3rd Parents/carers Contact Number

3rd Parents/carers Language

4th Parents/carers details

4th Parents/carers Relationship

4th Parents/carers Gender/Identifies as (pronoun)

4th Parents/carers Name

4th Parents/carers Ethnicity

4th Parents/carers Contact Number

4th Parents/carers Language

If Looked After or residing at a temporary placement. Placement/Temporary Address Including Postcode

Placement/Temporary Address Including Postcode

Is this Placement/Temporary address confidential?

Foster/temporary Carer Details

Foster/temporary Carer Relationship

Foster/temporary Carer Contact Number

Foster/temporary Carer Name

Foster/temporary Carer Language

2nd Foster/temporary Carer Details

2nd Foster/temporary Carer Relationship

2nd Foster/temporary Carer Contact Number

2nd Foster/temporary Carer Name

2nd Foster/temporary Carer Language

3rd Foster/temporary Carer Details

3rd Foster/temporary Carer Relationship

3rd Foster/temporary Carer Contact Number

3rd Foster/temporary Carer Name

3rd Foster/temporary Carer Language

Communication: Any Special Communication Needs? If yes please provide details

Any Special Communication Needs?

Registered/Statutory Status, Please give details of name of child/young person, dates, category (if known)

Any child in the family currently on a Child in Need Plan?

Any child in family is or has been on a Child Protection Plan?

Any child or other family member is/has been looked after by a local authority?

Any child in the family has a disability?

Any current criminal proceedings?

Referral Details

Name of Referrer*

Role of Referrer*

Contact Number of Referrer*

Email address of Referrer*

Name of Authorising Manager*

History of Case and Current Situation/Reason for Supervised Contact being Required

Case history*

Supervised Contact Details

** Please note that anyone not on the list below will not be permitted to join in the contact session.

Name of Person Attending Contact

Day/s of Contact

Relationship to Child

Start time

Contact number

Finish time

Frequency of contact (please specify, weekly, monthly, one off etc)

2nd Supervised Contact

Name of 2nd Person Attending Contact

2nd Person Day/s of Contact

2nd Person Relationship to Child

2nd Person Start time

2nd Person Contact number

2nd Person Finish time

2nd Person Frequency of contact (please specify, weekly, monthly, one off etc)

3rd Supervised Contact

Name of 3rd Person Attending Contact

3rd Person Day/s of Contact

3rd Person Relationship to Child

3rd Person Start time

3rd Person Contact number

3rd Person Finish time

3rd Person Frequency of contact (please specify, weekly, monthly, one off etc)

4th Supervised Contact

Name of 4th Person Attending Contact

4th Person Day/s of Contact

4th Person Relationship to Child

4th Person Start time

4th Person Contact number

4th Person Finish time

4th Person Frequency of contact (please specify, weekly, monthly, one off etc)

5th Supervised Contact

Name of 5th Person Attending Contact

5th Person Day/s of Contact

5th Person Relationship to Child

5th Person Start time

5th Person Contact number

5th Person Finish time

5th Person Frequency of contact (please specify, weekly, monthly, one off etc)

Please provide details below of any other Supervised contact.

**Please note anyone not detailed above or noted additionally below will not be permitted to join the contact session.

Include Name, Relationship, Days, Start & Finish times, Contact number and the frequency of contact (please specify, weekly, monthly, one off etc).

Contact Location

Does contact take place in a contact centre? Please provide address for contact location.

Can contact take place in the community or move into the community (for example, walking from the centre to a park)

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. Please give further detail if required

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)?

Please indicate the level of supervision required, provide extra detail if needed.

Select

Provide further details here.

Risk Assessment – Child, 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?

Has the young person/child(ren) displayed any sexualised/challenging behaviour?

Has the young person/child(ren) shown aggression towards other children or to adults?

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?

Are there any other risks that may be posed by the young person/child(ren) that the contact supervisor need to be aware of?

Risk Assessment – Adult/s, 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 provide details of where invoices for this service should be sent (Please note, referral will not be accepted if this section is not completed)

Name of contact for Invoicing*

Role of contact for Invoicing*

Department of contact for Invoicing*

Email of contact for Invoicing*

Telephone number of contact for Invoicing*

Authorisation

Authorising manager*

Date authorised*

Date authorised