Family Group Conferences - Worcestershire Referral Form July 2012 (2)

WORCESTERSHIRE FAMILY GROUP CONFERENCE PROJECT Referral Form

Referrer’s Name and Team Direct Line Working hrs. Email local authority

REFERRED CHILD/REN: Name Age Sex FWi No

OTHER CHILDREN IN THE FAMILY: Name Age Sex

CURRENT CAREGIVER: Name Relationship Address Phone

PARENTS: Name Address Phone

OTHER KNOWN FAMILY MEMBERS: Name Address Phone

Ethnic Origin of Family? Families First Language? Does the Family have a history of DV? Yes No Are you aware of any Police callouts for DV? Yes No Name & contact number of last attending Police Officer

D:\Docs\2018-04-14\073bdc068700319ed2f0f3908c42e231.doc Is the child on a Child Protection Plan? Is there an agency worker safety issue? Special needs of family/child e.g. disability:

OTHER AGENCIES/ SERVICE PROVIDERS INVOLVED: Name Agency Telephone

Reason for meeting: (Please include a brief description of the current situation, the proposed issues to be addressed and the desired outcome)

Family view of referral:

Young person’s view of referral:

Parent/ carer/ person with Parental Responsibility, agreement for FGC coordinator to contact them with a view to arranging a FGC: verbal acceptance and referral form uploaded to Fwi.

Family member & date agreed

Young person & date agreed

Referrers manager agreement

Please note, the referrer needs to attend the entire Family Group Conference Please Email or fax this referral to: The completed form has to be sent via the Single Point of Referral ([email protected] ). SW does not have to do the SPR form as well (unless they want other SSS services). If agreed a case note will be placed on FWi to confirm this decision and ask the worker to fax the referral to Daybreaks by secure email.

Date received Date of allocation Name of coordinator Date inputted

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