2.1 Child's wishes and feelings

3.1 Parent or family member requesting contact

3.2 Resident parent / current carer

3.3 Other relevant individuals

Please explain why supervised contact is being requested and what the intended outcomes are for the child and family.

Please attach copies of relevant court orders and provide clear details of any restrictions that may affect the service or the contact arrangements.

This section must be completed fully before the referral can be considered.

For each concern identified, provide details, relevant dates, current professional assessments and the measures required to manage the risk.

6.1 Current safety arrangements

Please attach relevant risk assessments, safety plans and safeguarding documentation. The contact service must complete its own suitability assessment before accepting the referral.

7.1 Proposed arrangements

7.2 Community-based contact

If community contact is requested, please specify:

All proposed locations and activities are subject to the service's risk assessment and approval.

Please outline the intended purpose of contact and how progress will be reviewed.

Please list relevant professionals involved with the family.

Please confirm which documents accompany the referral.

Only information relevant and necessary for the safe delivery of the service should be shared

DATA PROTECTION AND CONFIDENTIALITY

Information supplied through this form will be handled in accordance with applicable UK data protection legislation and the service's privacy policy. Information will be used for referral assessment, safeguarding, contact planning, record keeping and related lawful purposes.

Information may be shared with relevant professionals or statutory agencies where there is a lawful basis to do so, including where necessary to protect a child or another person from harm.

Please return the completed form and relevant supporting documents using the service's approved secure communication arrangements.