Application Form

Online Contact Application (Referral) Form

Please note that a non refundable fee of £100 is payable with this application. It will not be processed otherwise.

Please complete the fields below and click submit to authorise and apply online. Payment is taken via PayPal. On clicking ‘submit’ you will be transferred to the secure PayPal site to make your payment. * Indicates a mandatory field.

Name(s) of Child(ren)*

1. Referrer Details

Name*

Address*

Profession

Email*

Telephone*

2. Resident Parent or Carer Details

Name*

Relationship to child(ren)*

Address*

Email*

Telephone*

Parental Responsibility

3. Solicitor Name and Practice

4. Person requesting contact

Name*

Address*

Email*

Telephone*

Parental Responsibility

5. Solicitor Name and Practice

6. Cafcass/Social workers and other professionals involved

7. Contact History

Length of time since adult requesting contact met child(ren)*

Length of time since adult requesting contact lived with child(ren)

8. Contact Orders

When is the next court date?

Is there a Contact Order relating to contact?*

Who will be funding contact

9. Contact Details

Frequency and length of contact

Contact Level (supervised etc.)

Can contact take place outside of the centre?

Names of others allowed to participate in the contact

10. Safeguarding Information

Are there any historic or current sexual/child abuse allegations within this family? Please give details

Has any person been convicted of an offence against a child? Please give details

Is there a risk of abduction?yesno

Are there procedures in place? (holding passports etc.)

Please give details of any allegations, injunctions or convictions relating to violence in either party.

11. Health and Medical

Do any of the child/ren have any illness, allergy, disability, special needs or medical requirements? Please give details

Do any of the adults involved have any physical or mental illness or a disability? Please give details

12. Additional Information

Is a translator required?yesno

Previous experience of using a child contact centre?

Any other information

Referral Fee £100.00 GBP

I understand/confirm that the £100 referral fee is non refundable (please tick the checkbox to confirm)
By ticking the checkbox you consent to us contacting you.
Please review details of how we use information you supply in our Privacy and Data Protection Policies

You will be re-directed to PayPal on submission of this form.