Referral Form

/
Date of Referral / Date Received
Name / D.O.B. * / Family Address
Mother
Father
Child 1
Child 2
Child 3 / Telephone Number
Child 4

* Referred Children ONLY

Referrer’s Name / Area Team /

Designation

/ Telephone Number

Special Needs

/ YES/NO

Rate 1–5 (1 not good – 5 very good)

At risk of LAC / Communication within family
In LAC/Planned move / Contact between family members

Reason for Referral

Are there any past or present Child Protection concerns about the Child(ren)?

/ YES/NO
Please give brief details

Are the Children’s names currently on the Child Protection Register?

/ YES/NO
Have you any concerns about the safety of any member of the family or Co-ordinator if another member of the family should attend? / YES/NO
Please give brief details

What is the primary focus of the FGC?

What decisions need to be made about the child?

What is SC&H bottom line on this case?

What cannot be allowed to happen?

What is likely to happen if the FGC does not produce a plan that can care for/support and protect the child(ren)?

Significant Others – Family & Friends, with whom the child(ren) have contact?

Name / Address
Telephone
Relationship

Continued…

Name / Address
Telephone
Relationship

Continued…

Name / Address
Telephone
Relationship

Has the possibility of FGC been discussed with the family?

/ YES/NO

Has the possibility of FGC been discussed with the children?

/ YES/NO

Other Agencies/Professionals involved

Name / Address
Telephone
Designation

Continued…

Name / Address
Telephone
Designation

Continued…

Name / Address
Telephone
Designation
How would you describe this case? (Please tick all that apply)
Family Support / Child In Need / Child Protection
Family Breakdown / Looked After Child / Averting LAC
Care Proceedings / Article 8 Order / Domestic Violence
Young Parent / Young Carer / Disability
Drug/Alcohol Abuse / Mental Health / Other
Please specify if there is a certain time scale within which the Conference needs to be held
(Case Conference, Court Hearing, Reception into Care etc.)
Signed / Date

FOR OFFICE USE ONLY

Date of 1st Contact / Referral Accepted / YES/NO

Date FGC Held

/ Date of Review

Please tick appropriately

Conference Status… /

On hold

/ Not possible
Date
FGC 1st
FGC 2nd
FGC 3rd
Review

FGC, Unit 15, Cookson House, River Drive, South Shields, Tel: 0191 4969850