Referral Form On behalf of : This form must be completed with the family, who should be given a copy of the completed form. The Referrer must agree to attend the Family Group Conference to assist the process



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Referral Form

On behalf of :





This form must be completed with the family, who should be given a copy of the completed form.


The Referrer must agree to attend the Family Group Conference to assist the process.


The purpose of a Family Group Conference is:

  • For the family to hear information from the professionals about their contact with the family, and what support and services they could offer the family

  • For the family to consider any concerns about the children and the strengths which exist within their family

  • For the family to make decisions and come up with a plan that supports the needs of the children

  • For the referring professional to agree the family’s plan, and confirm that it does not put the children at risk

  • For the family to have the opportunity of a Review Family Group Conference if they feel this would help



Information about the children


Name of children

Gender

Where living?


Date of birth

     
     
     
     
     
     


     
     
     
     
     
     

     
     
     
     
     
     

     
     
     
     
     
     




Information about the family


Ethnic origin:       Family’s 1st language:      

Any special needs:       Any literacy support needed:      





Names, addresses and telephone numbers of extended family and significant others


Name

Relationship to the children

Address, postcode & phone numbers

     
     


     
     
     
     
     
     
     

     
     


     
     
     
     
     
     
     

     
     


     
     
     
     
     
     
     




Details of Referrer and Professionals involved with the children and their family


Name, Job Title and Location of Referrer

Contact Information

     


Please state the name of your team.
Supervising Managers Names (Must Provide):

     



(all 3 required)

Land Line:      


Mobile:      
Email:      
Tel      
Email:      

Name, Job Title and Location of other Professionals

Phone and Email address

     
     
     
     
     
     
     


     
     
     
     
     
     
     




Brief description of the current situation


     

Signs of Safety – Overall how would you rate the safety for the child/children 0 (High) to 10 (None)
     

As part of the safety plan what ‘worries’ would the FGC help address?


     

What is working well for the family?

     

* Note – referrers must submit a family tree or genogram, that includes the extended family. A referral may not be accepted without this.


Are there any Health and Safety Issues that the Co-ordinator would need to bear in mind when meeting with the family (e.g. concerning dogs, risky behaviour, etc) ?
     





What question(s) does the FGC need to address?

     



What would you not agree to in the family plan? For example action that would put the child at risk or resources not available.
     




Names, signatures & date

We agree to take part in the FGC process and to support the plans and decisions agreed.

We consent to the information on this form being shared with those involved in the FGC process.





Children

Family Member

Referrer

Line Manager


Sign















Print name
















Date













Referrals will not be accepted without the signature of a family member and the referrer. However, these can be sent separately in the post – an electronic referral will be accepted in the meantime to expedite the process.


Any questions on process can be directed to:


Gisella Thomas

FGC Champion for Reading Borough Council Referrals

Hamilton Centre,

135 Bulmershe Road

Reading, RG1 5SG
Phone: 0118 9373873

Email: eocs@reading.gov.uk




Juliet Penley

FGC Champion for West Berks Referrals

Phone: 01635 519093

Email: jpenley@westberks.gov.uk







Please return the completed form and family tree or genogram to:



Family Group Conferences (Reading & West Berks)

c/o of Hamilton Centre,

135 Bulmershe Road,

Reading RG1 5SG


0118 9373873

Email: eocs@reading.gov.uk





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