Name of Parent/Carer
Contact telephone number
Relationship to child/ren
Name of referrer
Name of Agency
Relationship to family
Has consent been sort for this referral?
If yes, from whom?
Please highlight the reason for this referral
Please provide us with information about the child/ren. Please include the following information: Child/ren's name, Date of Birth, Age, Gender, Residential Area and if you they are aware of parental imprisonment.
Relationship to child:
Contact telephone number:
Please provide the following information for each child:
Child's name, child's school and the named school contact.
Please tick the relevant boxes which reflect the family member/s health
No known disabilityLearning Disability/DifficultyAutism Spectrum DisorderMental Health DifficultiesPhysical ImpairmentMedical Conditions
If any of the health conditions above have been ticked, please give a brief description/s.
EHATChild in NeedChild ProtectionLooked After ChildNone of these
Please provide the following information for each professional involved with the family:
Name of professional, Agency name and when they were first involved with the family (mm/yy)
Which parent is imprisoned?
Is the child/ren aware of the imprisonment?
If no, where does the child/ren believe the imprisoned parent currently is?
Is support required to inform the child/ren of the imprisonment?
Please provide the following information which applies to the current status of the parent in the field provided below:
In Prison and expected month/year of release
or Due to go in to prison and the expected month/year
or Awaiting trial and expected trial date
or Has been released and the month/year of release.
Name of prison:
Are there any restrictions surrounding contact?
If yes, please provide details:
Does the child/ren currently have: (please tick relevant box/es)
Letter contactTelephone contactPrison visitsPost release contact (supervised)Post release contact (unsupervised)
Please input the date you are submitting this form:
Please add your signature in the box below:
You must have obtained consent from the child or child’s family before providing this information to us.
We need the above details to enable us to signpost the child to the right support and to be able to contact the family with information on our services.