Flourishing Families Form - SAFE Foundation

Eligibility criteria for this service:

Please check that the client meets the following criteria before making the referral:

Children eligible for support must be aged between 5-18 years.
Family must have experienced domestic violence and alleged perpetrator must not be living in the family home. They must not be in a new abusive relationship.
Any child contact with the perpetrator must be well managed.
Parent must be willing to fully engage with support alongside their child/ren.
Referrals must be completed by a Professional and not completed by a parent or young person.

Please note that the form will not submit with missing fields so please refer to your client to obtain this before completing the form. Please only state N/A where appropriate.

If you have any questions about our service or eligibility, please contact us on 03030 300 112.

Flourishing Families Referral Form

Step 1 of 6

16%

Service Category

Date of referral(Required)

DD slash MM slash YYYY

Referrer Name(Required)

Organisation Name(Required)

Job Title/Role(Required)

Referrer Phone(Required)

Referrer Email(Required)

Can SAFE contact CYP or Parent/Carer directly?(Required)

Right for Children number(Required)

Reason for Referral(Required)

Presenting Strengths of the family(Required)

What type of support does the parent/carer and child directly?(Required)

Is the non-abusive parent willing to engage in services including group work and one-to-one counselling prior to and alongside the children?(Required)

Yes

Family and contact information

With whom do the children live?(Required)

Parent/Carer details child resides with:

Name(Required)

First Last

Gender(Required)

Date of birth(Required)

YYYY slash MM slash DD

Phone(Required)

Email(Required)

This field is hidden when viewing the form

Geocoder

Address(Required)

Street Address Address Line 2 City County Postcode

Safe to contact (Phone)(Required)

Yes

Safe to contact (Mobile)(Required)

Yes

Safe to contact (Text Message)(Required)

Yes

Safe to contact (Email)(Required)

Yes

Preferred contact method(Required)

Text

Call

Contact Notes(Required)

GP Name(Required)

GP Surgery and Address(Required)

Next of Kin Name(Required)

Next of Kin Contact Details(Required)

(relationship, telephone and email)

Primary child referred

Name(Required)

First Last

Primary Child Gender(Required)

Date of birth(Required)

YYYY slash MM slash DD

Address(Required)

Street Address City Postcode

Phone(Required)

Email(Required)

Sibling Information

First Name

Last Name

Gender

DOB

Address

Phone

Statutory and other services

School contact name(Required)

School contact details (School name, telephone, email)(Required)

Education Healthcare Plan(Required)

Yes

Safeguarding Information

Is the child under Early Help?(Required)

Yes

Lead professional contact name(Required)

Lead professional contact details(Required)

Children's social care involved?(Required)

Yes

Don’t know

Level of social care involvement:(Required)

Child in Need (CIN)

Child Protection (CP)

Single Assessment

Supervision Order

Nature of social care involvement(Required)

Timeframe of social care involvement:(Required)

Current

Historic

Don’t know

Social Worker name(Required)

Social Worker contact details (telephone, email)(Required)

Are there any current safeguarding risks?(Required)

Details of any other services being accessed by the parent:(Required)

Domestic abuse

Mental health

Counselling/personal therapy

Addiction support (alcohol, drugs, gambling, etc.)

Other

None

If other, please specify(Required)

Details of any other services, diagnoses, or therapeutic input for the family(Required)

(e.g. PTSD, anxiety ADHD, Talkworks, play therapy, CAMHS)

Child support needs / vulnerabilities

Support Needs(Required)

Bullying/being bullied

Challenging behaviour

Child has attachment / communication with parent

Conflict as a result of contact

Eating issues

Educational attainment/attendance

Experiencing abuse

Mental health

Physical health

Self-harming/suicidal feelings

Sexual health

Sleeping issues

Social isolation

Substance misuse

Other (please specify below)

Additional Support Needs(Required)

Adult support needs / vulnerabilities

Adult Support Needs(Required)

Mental Health

Physical Health

Sexual Health

Substance Misuse

Challenging behaviour

Self-harming/suicidal feelings

Sleeping issues

Eating issues

Educational attainment / attendance

Social isolation

Bullying/being bullied

Experiencing abuse

Conflict as a result of contact

Adult Additional Support Needs(Required)

Alleged Perpetrator information

Perpetrator Name(Required)

Perpetrator Address(Required)

Perpetrator DOB(Required)

YYYY slash MM slash DD

Client relationship to perpetrator(Required)

Unfortunately, if your client is currently in a relationship with the alleged perpetrator, SAFE Foundation is unable to accept your referral. However, you may be eligible for support from Splitz. You can contact their service on 0345 155 1074 or https://www.splitz.org/contact-us.html

If other, please specify(Required)

Child contact with perpetrator(Required)

Are there any outstanding court orders?(Required)

Yes

If there is more than one alleged perpetrator, please provide additional details in the box below(Required)

Does the alleged perpetrator have a diagnosed or undiagnosed problem with mental health, substance misuse, or alcohol?(Required)

Yes

Don’t know

Please state whether there has been any violent or aggressive behaviour from the alleged perpetrator to agency workers or other members of the public?(Required)

Yes

Don’t Know

Parental rights of the alleged perpetrator(Required)

Is the alleged perpetrator accessing a support service to access the above?(Required)

Yes

What kind of contact does/do this child/ren have with the alleged perpetrator?(Required)

How does/do the child/ren feel about contact?(Required)

Has the alleged perpetrator sought access to the child/ren without prior agreement from the non-abusive parent?(Required)

Does the alleged perpetrator use contact or any other methods as a tool to inflict further harm/power and control on the child/ren and the non-abusive parent?(Required)

Family Information

Children’s emotional and mental health

Consider:

How do they feel about what’s happened (angry, sad, guilty, scared)?
How do they manage angry/ sad feelings?
Any issues around aggressive behaviour towards peers/ adults?
Coping strategies – using alcohol or drugs?
Any suicidal thoughts or feelings?
How do they feel about themselves – their self-esteem and confidence?
Any self-harming behaviour?
Any diagnosed/ undiagnosed mental health conditions?

Notes(Required)

Family life

Consider:

How safe/ happy do they feel at home?
What is their relationship/ attachment like with the survivor/ non-abusing parent?
What is their relationship like with siblings/ other family members?
Do they have support from extended family?
How does parent set boundaries, and how does child respond to this?

Notes(Required)

Education and social life

Consider:

How much do they enjoy/ attend nursery/school/college?
What hobbies or out of school activities do they enjoy?
Do they have friends they can talk to about things that worry them?
If they have a boyfriend/ girlfriend, what is that relationship like?

Notes(Required)

Abuse information (non-abusive parent/carer perspective)

Consider:

How do you think the violence has affected your relationship with your child?
Is your child abusive towards you?
Do you feel guilty or to blame?
What do you perceive your child’s role within the family to be?
Did you sustain any injuries that have impacted on your parenting?
Have you ever been forced to prioritise your partners needs over your child’s?
Has the child heard you be criticised and insulted by your abusive partner?

Notes(Required)

Accessibility/Demographic requirements

Is it safe for a worker from SAFE Foundation to visit the home in which the child resides?(Required)

Yes

Please give details of risks in the home(Required)

Accessibility needs(Required)

Interpreter required(Required)

Yes

Accessibility information(Required)

Does your client have a disability?(Required)

Physical

Learning

Mental Health

Hearing Impaired

Visually Impaired

Other

None

What is their ethnicity?(Required)

White British

White Irish

White Gypsy or Irish Traveller

Asian British

Asian Indian

Asian Pakistani

Asian Bangladeshi

Any other Asian background

Chinese

Arab

White and Black Caribbean

White and Black African

White and Asian

Any other mixed, multiple background

Black British

Black African

Black Carribean

Any other background

Don’t know

Other (please specify)(Required)

What is your clients religion or faith?(Required)

No religion

Bahai

Buddhist

Christian

Hindu

Jewish

Jain

Muslim

Shinto

Sikh

Zoroastrian

Other

Don’t know

Other (please specify)(Required)

What is their current relationship status?(Required)

Civil Partnership

Married

Divorced

Seperated

Cohabiting but not married / CP

In a relationship (not cohabiting)

Widowed

Single

What is your clients sexual orientation?(Required)

Heterosexual

Gay Woman / Lesbian

Gay Man

Bisexual

Other

Prefer not to say

Other (please specify)(Required)

Is your client pregnant?(Required)

Yes

Don’t know

Prefer not to say

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