Family mediation with support - referral form

Refer a young person or family to Reconnect

The information you provide on this form will help us understand if the young person and their family would benefit from family mediation.

Please complete the form to the best of your ability. The information marked as mandatory must be completed before we can process the form.

We may need to get in touch with you for further information or clarification. Where possible, please respond within two working days so we can help the family as quickly as possible.

Family mediation can only take place where the home environment is safe for everyone involved. Please contact 0333 335 7343 if the young person you are referring is not safe in the home.

How we use your information

At the beginning of each section, we explain why we ask for the information and who it may be shared with. Please make sure the person you are referring understands how their personal information will be used.

We ask for this information to:

Help us understand their circumstances and assess whether Reconnect is right for them

Make sure any support offered is safe and appropriate for everyone involved

Help us understand who uses the service and identify trends, so we can improve the support we provide

We take privacy seriously. Information is stored securely and accessed and shared in line with our data protection responsibilities.

Please obtain consent from the family you are referring before submitting this application

Primary young person details

To ensure we have the correct contact details to successfully contact the young person to arrange mediation and support sessions. Optional demographic details are to help monitor trends in support

First Name

Last Name

D.O.B

Date format: DD/MM/YYYY

Preferred method of contact for young person

Young person's contact number

Email

Ethnic origin

Gender

NHS number known

Created by FA

Care leaver [HL]

Page 3

Address

House or Flat Name/ Number

Region

Street name

Post code

Page 4

Referral details

We use this information to get a picture of the situation at the point of referral to assess suitability for support and to inform the initial risk assessment

Reason for referral

How many people in household

Is there a lone-working risk to staff?

RecordTypeId

Page 5

Overview

Overview of the problem

What is currently causing breakdowns in family relationships and communication?

What would the Young Persons want to change to improve the relationship:

Main area parent/carer wants to change to improve the relationship:

What do the Parent/Carer’s want to change to improve the relationship:

Parent guardian details

Parent/ Guardian 1

P1. First name

P1. Last name

P1. Contact number

P1. Relationship to child

Add an additional parent / guardian

Parent/ Guardian 2

P2. First name

P2. Last name

P2. Contact number

P2. Relationship to child

Referer details

About the referer

Name

Email

Contact number

Organisation