Ethnic Origin of the Family? Family’s First Language? Does the Family have a history of DV? Yes No Are you aware of any Police callouts for DV? Yes No Name & contact number of last attending Police Officer Does the child/ren have an advocate in place? Yes No Is it likely that the child/ren will need an advocate? Yes No When visiting the family home are there any safety issues? e.g. dogs. Yes No If yes, please describe: If risk is significant the referrer is responsible for sharing a risk assessment with the conference coordinator Are there any special needs within the family/child? e.g. disability. Yes No If yes, please outline: Other service providers involved: Name Agency Telephone Reason for meeting: (Please include a brief description of the current situation and if known the proposed questions to be addressed) Family view of referral: view of referral: Young person’s I agree with information being shared with the coordinator for the purpose of the Family Group Meeting. Are the family in agreement of this referral being Yes No Date discussed: made? signature Referrer’s line manager and contact details Referrer’s Please note: the referrer needs to attend the entire Family Group Conference Please email this referral to: BOURNEMOUTH REFERRALS POOLE REFERRALS Brokerage Officers Alison Powney (Programme Manager) Bournemouth Town Hall Daybreak FGC Access to Resources Team, Extension 3 West Lodge Leylands Farm, Bourne Avenue Nobbs Crook Colden Common BH3 6DY Winchester SO21 1TH 01202 458012 02380 696644 Date received Date of allocation Name of coordinator Date inputted
Ethnic Origin of the Family? Family’s First Language? Does the Family have a history of DV? Yes No Are you aware of any Police callouts for DV? Yes No Name & contact number of last attending Police Officer Does the child/ren have an advocate in place? Yes No Is it likely that the child/ren will need an advocate? Yes No When visiting the family home are there any safety issues? e.g. dogs. If yes, please describe: Yes No If risk is significant the referrer is responsible for sharing a risk assessment with the conference coordinator Are there any special needs within the family/child? e.g. disability. If yes, please outline: Yes No Other service providers involved: Name Agency Telephone Reason for meeting: (Please include a brief description of the current situation and if known the proposed questions to be addressed) Family view of referral: Young person’s view of referral: I agree with information being shared with the coordinator for the purpose of the Family Group Meeting. Are the family in agreement of this referral being made? Yes No Date discussed: Referrer’s signature Referrer’s line manager and contact details Please note: the referrer needs to attend the entire Family Group Conference Please email this referral to: BOURNEMOUTH REFERRALS POOLE REFERRALS Brokerage Officers Alison Powney (Programme Manager) Bournemouth Town Hall Access to Resources Team, Extension 3 Bourne Avenue BH3 6DY Daybreak FGC West Lodge Leylands Farm, Nobbs Crook Colden Common Winchester SO21 1TH 01202 458012 02380 696644 Date received Date of allocation Name of coordinator Date inputted
Family%20Group%20Meeting%20Referral%20Form.docx