This Form should be filled out by Social Workers who are 1) requesting a room for family time in a centre and/or 2) requesting Family Time Supervisors to supervise. Allocated supervised family time requests will be confirmed once the necessary arrangements have been made. All sections must be completed. Any incomplete referrals will be rejected and no further work undertaken until the updated form has been returned and receipt acknowledged.

1. Names of children who need family time: Name DOB Gender CareFirst ID Disability Ethnicity Legal Status School

2. Is the child subject to Child Protection Plan? If so what category? Emotional, Neglect, Sexual, Physical Proceeding arrangements:

3. Name and address of where child is currently placed and carer’s details: Name: Address: Contact numbers: Email address: Date child placed: Is the Placement address Confidential from Parents?

4. Name(s) of Social Worker / Advanced Practitioner / Team Manager / Team and Address of their main work base and contact numbers (all areas need to be completed): Team name: Name Address Tel No Social Worker: Advanced Practitioner: Team Manager:

5. Name and contact details of Children’s Guardian(s) – CAFCASS (if applicable) Name Address Tel No

6. Summary of Background Information: Please provide a summary of the child’s history and why family time is required:

7. Name and contact details of child(ren)’s parents / the person who has parental responsibility. Name DOB Gender Address + Tel No Relationship Parental Responsibility (Yes / No)

8. Can parents / family members meet or have family time together (if appropriate)? Please be specific about which members of the family can have family time together and those that cannot, and those who cannot cross paths.

9. Details of any specific needs/arrangements for either child(ren) or adults attending family time For example: Does the child need a specific type of car seat? Have community/home venues been risk assessed? Venue accessibility, room requirements? Are there any Health & Safety issues? Who will supervise the child while waiting for the family time supervisor? Include medical or health conditions, for example autism, ADHD, epilepsy, if medication is required during sessions, etc? Communication needs? Does the child have any specific religious / cultural needs?

10. Risk Assessment: Include description of any relevant incidents or hazards, include incidents involving children, adults, and staff. Make recommendations to address each incident / hazard to reduce the risk associated with the hazard – please be specific. Has a Family Time Agreement been completed and signed? Yes No Have any of the service users ever been convicted of physically harming a child? Yes No If yes, please specify Have any of the service users had an allegation of physical harm made against them? Yes No If yes, please specify Have any of the service users had a conviction for sexual assault on a minor? Yes No If yes, please specify Have any of the service users ever had allegations made of sexual contact with a child? Yes No If yes, please specify Are there / have there ever been any concerns around emotional abuse of children/young people? Yes No If yes, please specify Are there any risks of abduction? Yes No If yes, please specify Are there any risks relating to verbal abuse? Yes No If yes, please specify Are there any other risks relating to the service user? Yes No If yes please specify

11. Is there any other information that you feel would be relevant to safeguarding the children involved in the family time? E.g., can parent(s) leave the building at the same time as the child/ren? Can parent(s) meet the foster carer?

12. What level of supervision is required? Assess the need of level for supervision of family time based on level of risk – Low can be in the community, Medium in a family time venue or community venue, and High in a family time venue after meeting and risk assessment completed High Medium Low Can personal care be undertaken? Can child/ren go to the toilet on their own?

13. Useful information: Can those attending give presents/cards? Can those attending provide food, including sweets and soft drinks? (Please be specific as to what can / cannot be provided) Can those attending take photographs? (It is expected that telephone calls will not be allowed in the sessions, although mobile phones may be used for their camera facilities) Can those attending take video? Details of any allergies / health issues? Who will be paying for any activities if a community session? What to do if the child/ren / parent does not attend?

14. Family time arrangements (location for family time; which days; start and end time for family time; frequency; attendees; transport arrangements etc. Please advise if not known. Please note that this needs to be in line with venue and staff availability and so may need to change from the actual request) Venue (please confirm if this is being requested or has already been booked): Day/s: Time: Availability of parent(s) and child(ren) - please detail any days / times when the parent(s) and/or child(ren) will not be available for family time. Please be as clear as possible: Frequency of sessions (e.g. 1 x a week, fortnightly etc) Attendees: Please ensure that you advise who will be attending on the requested days, e.g. the mother on one day and the father on another ? Planned Transport arrangements ? (Carers are expected to assist for stability):
Is an interpreter required, if so which language? ___________________ Is an interpreter currently in place? Yes No If yes, please give details:

15. Please indicate which areas of assessment you want observed and recorded within the family time recording. Include anything that should be observed, where the Family Time Supervisor should prompt / intervene. Note any court directions and if life story work should be undertaken. What outcomes are expected to be achieved from supervised family time? Please detail what indicators will demonstrate this has been achieved.

16. Dates / Details for review meeting (as agreed at LAC Reviews, Courts, but may need to be considered between these events on a minimum 3-monthly basis with the social worker). LAC Review date: Court date: Court Plan (if not known please update when this is available):

Social Worker:	Date
Completed By:	Date
Position:

Once fully completed (please ensure all sections are responded to) please send the referral and family time agreement to: contactteamncc@nctrust.co.uk