Professional Submission Form - Lewisham Children & Family Centre

The Community Groups Programme	The Freedom Programme
The Community Groups Programme is a twelve-week therapeutic programme for women and children who have experienced domestic abuse. It seeks to enable the recovery process and aims to: • Validate the children’s experiences. • Reduce the self-blame that is commonly associated with children experiencing abuse. • Develop a child-appropriate safety plan. • Manage appropriate and inappropriate expressions of emotion. • Enhance the mother-child relationship. • Enable both the mother and child to heal together.	The Freedom Programme is for women who are experiencing or surviving domestic abuse. It usually runs for eleven or twelve weeks (but this may vary depending on your locality) and aims to: • Provide women who are experiencing or surviving domestic abuse with a safe, supportive and friendly environment. • Allow women to recognise the tactics and behaviours of ‘the dominator’ – that is, the tactics that typify a perpetrator of domestic abuse. • Give women the opportunity to build connections with other women.

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FIRST NAME	SURNAME	M/F	RELATION TO CHILD	D.O.B	ETHNICITY	RELIGION	NHS NUMBER

FIRST NAME	SURNAME	M/F	D.O.B	SCHOOL	CPP/CIN	ETHNICITY	RELIGION	NHS NUMBER

NAME	RELATIONSHIP TO FAMILY	ADDRESS and POSTCODE	TEL / MOBILE	E-MAIL	SAFE TO CONTACT?	SAFE CONTACT NOTES

Welcome to the Early Years Alliance Lewisham Services Website

Professionals Referral Form

Step 1 of 5

SECTION A: REQUIRED INFORMATION ABOUT THE REFERRER and the FAMILY BEING REFERRED

PROFESSIONALS WORKING WITH FAMILY

SECTION B: REFERRAL DETAILS

SECTION C: REFERRALS FOR THE COMMUNITY GROUPS PROGRAMME, THE FREEDOM PROGRAMME AND/OR WHERE DOMESTIC ABUSE HAS BEEN EXPERIENCED

INFORMATION ABOUT THE PERPETRATOR/ALLEGED PERPETRATOR (IF KNOWN)

SECTION D: FAIR PROCESSING AND CONSENT FORM

Name	Tel	E-Mail

Name	Tel	E-Mail

Name	Tel	E-Mail

Name	Tel	E-Mail