/ DERBY CHILD CONTACT CENTRE
“Working with Families to put Children First”
Affiliated to and Accredited by the National Association of Child Contact Centres
Derby Child Contact Centre, Ruth’s Place, 100 Canal Street, Derby. DE12RJ
Tel: 01332 298130

Self Referral Form and Agreement for Supported Contact

This form must be completed in full, in block capitals, and submitted to the above address by post, or brought in person to a pre-arranged interview. A separate form must be completed by each parent. The Centre charges a one-off referral fee of £25 and this should be sent with the form; referrals will not be processed until the fee is paid. No contact can take place until you receive written notification of dates and times from the Centre.

Contact (Non-Resident) Parent

Name:
Address:
Telephone
Number / Home / Mobile
Your relationship to the child/ren
Do you have legal parental responsibility for the child/ren? / Yes / No
Children
Name(s): / DOB: / Gender (M/F)

The other parent

Their name:
Their address and/or tel. no:
When did your relationship with the other parent end?
Why did your relationship with the other parent end?

When did you last:

/

a)see the child/ren

b)live with the child/ren

Has your family ever been known to or been involved with any of the following:if Yes, please give details on a separate sheet

CAFCASS / Yes / No / Social Services / Yes / No
The Courts / Yes / No / Mediation Services / Yes / No
Do you have any concerns relating to domestic violence, drugs alcohol or mental health issues? / Yes / No
If yes, please give details:
Do you or the other parent have any convictions? / Yes / No
If yes, please give details

Previous Contact:

WHEN and WHERE did contact last take place?
WHO was involved in the contact?
WHY did the contact breakdown?
If they are old enough to understand and have a view, how do the children feel about having any contact?

Arrangements for Contact:

Would you prefer contact
at the Centre: (please tick) / in the morning / in the afternoon / no preference
How long would you like a contact session to be? / 1 hour / 2 hours / 3 hours
Would you wish anybody else to be involved in the contact
(if the other parent agrees) / Yes / No
If yes, who?
Are you in contact with / able to talk to the other parent? / Yes / No
Are you prepared to meet the other parent? / Yes / No
Will staggered arrival / departure times be required / Yes / No
Would you wish to take the children out of the Centre
(if the other parent agrees) / Yes / No
Do any of the children have any illnesses or allergies?
What language is spoken at home?
Will an interpreter be needed? / Yes / No
If yes, are you or the other parent prepared to pay for the interpreter? / Yes / No
Are there any other issues you feel the centre needs to be aware of?

Agreement:

  • 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 Centre’s rules or conditions.
  • I enclose £12.50 / £25 being the Centre’s Referral Fee (or my share of that fee)

Signed / Contact Parent
Print name / Contact Parent
Date
Signed / Derby Child Contact Centre
Print name / Derby Child Contact Centre
Date

Self Referral Form: Contact Parent

Revised January 2015Page 1 of 3