Parent Referral Form for Supervised Child Contact Services

Thank you for choosing Compass Family Time. This form allows us to gather some basic information so that we can discuss your family's needs and decide whether our service is suitable. Once we receive your referral, we will contact you to arrange a Child Agreement Meeting. This is an individual meeting with each parent or family member to discuss the child's needs, contact arrangements, and any safety considerations.

Your Details

First name

Last name

Relationship to child(ren)

Home Address

Street address

Address line 2

Town/City

Postcode

Telephone number

Your email address

Child(rens)'s Details

Child(ren)’s Details

Child’s Name

Date of Birth

Age

Who do the children currently live with?

Do you have Parental Responsibility?

Yes

No

Other Parent / Family Member

First name

Last name

Relationship to Child(ren)

Phone Number (if known)

Email Address (if known)

Is the parent/family member aware that you are making this referral?

Has their consent been gained?

What services do you need?

Supervised Community Contact

Supervised Contact (requires an indoor venue only)

Handover Service

Unsure what service is needed

Why Are You Referring?

Please briefly tell us about the current situation and why you would like support from Compass Family Time.

Previous Contact

When did the child(ren) last see the other parent/family member? Please briefly explain what contact arrangements have been in place previously.

The Child(ren)'s Views

How does your child feel about seeing the other parent/family member?

Safety and Wellbeing

To help us assess whether contact can take place safely, please tick any areas that apply:

Compass Family Time must be made aware of any risk, safeguarding, or welfare concerns that may affect the safety of children, family members, or staff. Failure to disclose relevant information may result in services being suspended or withdrawn.

Domestic Abuse

Police Involvement

Mental Health Concerns

Drug Misuse

Alcohol Misuse

Conflict Between Adults

Child Protection Concerns

Court Proceedings

Other Concerns

If you selected any of the above, please provide brief details:

Court Proceedings

Are there any current court proceedings?

Yes

No

Court details:

Next Hearing Date:

File Upload

Please attach copies of any Court Orders, Injunctions, Non-Molestation Orders, Restraining Orders or Bail Conditions that may be relevant to contact arrangements.

Health and Additional Needs

Do any children or adults have medical conditions, disabilities, additional needs or allergies?

Yes

No

If yes, please provide details of relevant health conditions, needs or allergies

Service Fees

Service	Fee
Referral Fee	£60
Child Agreement Meeting (CAM, a meeting is required with each parent/family member)	£50 per parent plus travel
Child Preparation Session (if required)	£40 plus travel
Supervised Contact — 90 minutes	£150 plus travel
Supervised Contact — 120 minutes	£200 plus travel
Community Handover	£50 plus travel
High Conflict Handover	£80 plus travel

Travel is charged at 55p per mile plus £15 per hour of travel time. A full quotation will be provided before services commence.

Payment Responsibility

Please confirm who will be responsible for payment:

Parent requesting the service

Shared equally between both parents

Solicitor

Local Authority

Other

Other Payment Responsibility — please specify:

Name of person/organisation responsible for payment:

Payment Agreement — Please tick to confirm:

Where payment responsibility is unclear or disputed, Compass Family Time reserves the right to postpone services until a written agreement regarding funding has been received.

I understand that payment must be received before services are delivered.

I understand that Compass Family Time cannot proceed with sessions unless payment arrangements have been agreed.

I understand that cancellation charges may apply.

I confirm that I am responsible for ensuring agreed costs are paid.

Declaration

I confirm that the information provided is accurate to the best of my knowledge and understand that Compass Family Time may request additional information before accepting a referral.

I confirm

Your Full Name:

Your Signature

Referral date

Parent Referral Form

Parent Referral Form for Supervised Child Contact Services

Your Details

Child(rens)'s Details

Service Fees

Declaration

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