Who is making this referral?

Parent/Carer - complete 1a
Agency (school, CAMHS, GP, children’s services, etc) - complete 1b

1a. Parent/Carer

Name of Parent/Carer

Parent/Carer Email

Contact telephone number

Relationship to child/ren

1b. Agency

Name of referrer

Name of Agency

Referrer Email

Contact telephone number

Relationship to family

All parties to complete the following:

Has consent been sort for this referral?
YesNo

If yes, from whom?

Reason for referral

Please highlight the reason for this referral

About the family

Family name:

Family address:

Contact number:

Email address:

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.

Name of person/s with parental responsibility

Full name:

Relationship to child:

Contact telephone number:

School

Please provide the following information for each child:
Child's name, child's school and the named school contact.

Health

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.

Other information:
EHATChild in NeedChild ProtectionLooked After ChildNone of these

Professionals involved with family

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)

Imprisoned parent

Which parent is imprisoned?
MotherFatherOther

Is the child/ren aware of the imprisonment?
YesNo

If no, where does the child/ren believe the imprisoned parent currently is?

Is support required to inform the child/ren of the imprisonment?
YesNo

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.

Are there any restrictions surrounding contact?
YesNo

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)

Sign and Date

Please input the date you are submitting this form:

Please input your full name in the box below:

I agree that I have obtained consent from the child or child’s family before providing this information to Time-Matters UK.

For more information on how we use and process personal data, please refer to our privacy policy.