Birmingham Child Contact Centre

Referral Form - Professionals and Practitioners

Wherever possible this form needs to be seen and completed either of both parties Solicitors/Practitioners or a Solicitor/Practitioner on behalf of both parties.

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 parents/guardians, in case of emergencies.

All information is treated in strict confidence.

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

Name
Profession
Address
Postcode
Landline
Mobile (required)
Email