Hall Green and North Solihull Child Contact Centres

Hall Green and North Solihull Contact Centres

Self Referral Form

Page 1 of 2

Contact Centre

Contact Centre:

Children

Child 1:

Name
Age
Date of birth
Boy or Girl

Child 2:

Name
Age
Date of birth
Boy or Girl

Child 3:

Name
Age
Date of birth
Boy or Girl

Child 4:

Name
Age
Date of birth
Boy or Girl

Details of person seeking contact

Name
Address (You can decline to disclose this if you wish)
Postcode
Telephone (Landline)
Mobile
EMail

Details of the person with whom the children live

Name
Address (if known)
Postcode
Telephone (Landline)
Mobile
EMail (if known)

Relationship

When did your relationship break down?
Why did your relationship break down?

Services

Has your family ever been known to or been involved with any of the following:

CAFCASS
If yes please give dates and details
Social Services
If yes please give dates and details
The Courts
If yes please give dates and details

Is there a Court Order in relation to Contact or other child arragements ?
If yes please send a copy or indicate what it contains. If there is more than one order please send or provide details of the most recent order.

Mediation services
If yes please give dates and details

Do you have any concerns relating to domestic violence, drugs, alcohol or mental health issues ?
More information
Do you or the non-resident parent have any criminal convictions and/or cautions?
If yes please give details

Legal Advice

Do you have a solicitor or legal adviser? If yes please provide full contact details including firm name, legal adviser name and telephone number and/or email address. WE WILL NOT CONTACT YOUR SOLICITOR WITHOUT YOUR PRIOR CONSENT.