Birmingham Child Contact Centre

Self - Referral Form - For Parents, Family Members, etc.

This form should be completed by either party, on behalf of a resident parent and non-resident party.

Note – all questions should be answered. If any are unknown, please enter “NA”.

Contact cannot begin until this form has been completed and accepted by BCCC’s Coordinator.

It is essential to include the contact details of both parties, in case of emergencies.

All information is treated in strict confidence, please see our Confidentiality and Privacy Policies on this website.

Please call 07447 752900 for any assistance in completing this form

Page 1 of 3 - Personal Details

1. Children

Child 1:

Name
Date of birth (DD/MM/YYYY)
Age
Gender

Child 2:

Name
Date of birth (DD/MM/YYYY)
Age
Gender

Child 3:

Name
Date of birth (DD/MM/YYYY)
Age
Gender

Child 4:

Name
Date of birth (DD/MM/YYYY)
Age
Gender

2. Adult requesting contact

Name
Date of birth (DD/MM/YYYY)
Ethnic Origin (assists funding)
Relationship to child

Does this person have legal parental responsibility?
Length of time since they met with children
Length of time since they lived with children

Address (May be withheld)
Postcode
Landline
Mobile (required)
Email

Solicitor's name
Solicitor's ref
Name of practice
Address
Postcode
Landline
Mobile (required)
Email

3. Adult with whom the child(ren) reside

Name
Date of birth (DD/MM/YYYY)
Ethnic Origin (assists funding)
Relationship to child

Does this person have legal parental responsibility?

Address (May be withheld if you wish)
Postcode
Landline
Mobile (required)
Email

Solicitor's name
Solicitor's ref
Name of practice
Address
Postcode
Landline
Mobile (required)
Email

4. Referrer (if different to adult parent / carer requesting contact)

Name
Relationship
Address
Postcode
Landline
Mobile (required)
Email

Page 2 of 3 - Safeguarding and Official information

5. Court, CAFCASS & Contact Orders

a. Has CAFCASS been involved?
b. Is there an allocated CAFCASS officer?
If Yes, please advise name
Email address
Phone number
c.1 When did contact last take place?
c.2 Where did contact last take place?

d. Is there a Child Arrangement / Court Order relating to the contact?

If Yes, please upload a copy at the end of the form.
e. Please give brief details of any previous arrangements (formal or informal) or parenting plans in relation to child arrangements and how they have broken down in relation to contact
f. Can the child(ren) be taken out of the Centre?
g. What is the next court date (if any)?

6. Arrival at the Child Contact Centre

a. Are the parents willing to meet?
b. Will the adult with whom the child(ren) reside be bringing them to and collecting them from the Centre?
If 'No', who will be bringing / collecting the child(ren)?

c. What is the preferred date of first contact at the Child Contact Centre?
d. How frequently will contact take place?
e. Preferred length of time each visit will last?

f. Names of other people allowed to participate in contact at the Child Contact Centre:

Person 1 - Name
Person 1 - Relationship to child
Person 2 - Name
Person 2 - Relationship to child
Person 3 - Name
Person 3 - Relationship to child

7. Information Relating to Safety of the Child

a. Are there or have there been allegations of physical / sexual abuse or neglect made in this family? If 'Yes', please give details
b. Are there or have there been allegations of domestic abuse within the family? If 'Yes', please give details of any allegations, undertakings, injuctions, convictions or restraining orders.
c. Is this family known to Social/Children's Services? If 'Yes', please give details
Name of social worker
Email address
Phone number
d. Has any person who will be involved in the contact ever been convicted of an offence against a child(ren)?

If 'Yes' to a, b or c or d above please give details

e. Has there been or is it likely to be a risk of abduction? If 'Yes', please give details.
If Yes, are procedures in place for holding passports, etc.
f. Please give details of any allegations, undertakings, injunctions or criminal convictions and cautions relating to violence involving either party, their respective families or the children.
If currently engaging with probation/police, please provide details of probation officer or police offender manager.
Name
Email address
Phone number

Page 3 of 3 - Further information and completion

8. Health & Medical Requirements

a. Do any of the children have any illness, allergy, impairment, special needs or medical requirements?
If Yes, please give details
b. Do any of the adults involved suffer from long-term physical / mental illness or an impairment?
If Yes, please give details

9. Additional Information

a. What language is spoken at home?
b. Is an interpreter required?
If Yes, you should provide one acceptable to both parents (include name and organisation if any)
c. Has this family ever used another Child Contact Centre?
If Yes, please give details (this Centre may be contacted).
Please provide any additional background information that you feel necessary.

Court Orders and any other relevant additional documents should be uploaded below. These are required to ensure that BCCC does not compromise anything that a court requests. Doing so may hold Birmingham Child Contact Centre in contempt of court.

Please ensure all documents have been fully uploaded, before submitting this form.

Upload files

I confirm that I have read, or have had the opportunity to read, the Birmingham Child Contact Centre Welcome Leaflet/Guidelines which are available on www.birmccc.org.uk

This form has been completed accurately and to the best of my knowledge.

Sometimes, we may have a waiting list. If this occurs, we will advise when we reply to your Referral.

Referral completed by (name)

Thank you for completing this form.
You will be contacted in the next few days