<p>WORCESTERSHIRE FAMILY GROUP CONFERENCE PROJECT Referral Form</p><p>Referrer’s Name and Team Direct Line Working hrs. Email local authority</p><p>REFERRED CHILD/REN: Name Age Sex FWi No</p><p>OTHER CHILDREN IN THE FAMILY: Name Age Sex</p><p>CURRENT CAREGIVER: Name Relationship Address Phone</p><p>PARENTS: Name Address Phone</p><p>OTHER KNOWN FAMILY MEMBERS: Name Address Phone</p><p>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</p><p>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:</p><p>OTHER AGENCIES/ SERVICE PROVIDERS INVOLVED: Name Agency Telephone</p><p>Reason for meeting: (Please include a brief description of the current situation, the proposed issues to be addressed and the desired outcome) </p><p>Family view of referral:</p><p>Young person’s view of referral:</p><p>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.</p><p>Family member & date agreed</p><p>Young person & date agreed</p><p>Referrers manager agreement</p><p>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.</p><p>Date received Date of allocation Name of coordinator Date inputted</p><p>D:\Docs\2018-04-14\073bdc068700319ed2f0f3908c42e231.doc</p>