Reconnect: Family mediation with support - referral form

If you are a professional looking to refer a young person or family member, please complete the referral form below.

If you are a young person, parent, carer, or family member wishing to self-refer, please call our national Reconnect phone line on 0333 335 7343. Please note that the phone line is monitored Monday to Friday, 9am–5pm (excluding bank holidays).

Alternatively, you can email us at reconnect@depaulcharity.org.uk.

The information in this form helps determine whether the young person/family is suitable to engage with Mediation services. Please complete this form in full. All information is mandatory unless stated otherwise. Any missing information could result in the referral being automatically declined. By submitting this form, you agree to respond to any requests for clarification information within 2 working days.

Please note that mediation can only occur if the home is safe for the young person.

At the start of each section, we explain why we collect that particular piece of information and with whom we share it. This is important to ensure everyone understands how we use their personal information. Please read this out loud to the person you are referring to so they are clear.
In addition, please share the following statement with all people referred for support:

Privacy notice

When we receive referrals for Reconnect, we collect your personal and sensitive information. You have a right to know who has access to your personal information and with whom it is shared.

The Reconnect service will ask for various pieces of information to:

Help assess whether you’re suitable for Reconnect

Ensure it’s safe for you and for others involved

Monitor trends about who uses the service.

This is to help us improve the service and better understand who we help.

We take good care of your details, and they are always safe with us. We store all this information on our secure database.

For more information, contact: dataprotection@depaulcharity.org.uk or read our Privacy notice https://www.depaul.org.uk/data-protection-and-privacy-statement/

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

Region

Ethnic origin

Gender

House or Flat Name/ Number

Street name

Post code

NHS number known

Created by FA

Care leaver [HL]

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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?

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:

RecordTypeId

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