DA Surgeries Professional Submission Form Step 1 of 3 33% First Name* Surname* Email* Phone*Role* Please indicate which training programmes you have completed (if any):*NoneDomestic Abuse AwarenessFreedom ProgrammeCommunity Groups ProgrammeEscape the TrapCaring DadsI agree by attending the Professionals Surgery that anything discussed will remain confidential unless we are worried about aspects of the case or that you, or someone close to, is at risk of harm. I also agree that all case information has been anonymised for the purpose of discussion with external professionals:Consent* I agree to the above What plan is the child(ren) currently on?CPCINHow long have the family been known to CSC?Less than a year1-2 years3-5 yearsMore than five yearsIs there a Child and Family Assessment in progress?YesNoHas there ever been a Legal Planning Meeting for this family?YesNoAre there any current orders in place with regards to the child(ren)?YesNoWhich orders are in place?Supervision OrderInterim CareFull Care OrderFull Care Order with PlacementHas this case been heard at MARAC?YesNoUnknownIf yes when?*20202019201820172016201520142013201220112010Is there a current criminal case or history of criminality with the perpetrator?YesNoIf yes, please detail criminal offences and yearsIs the victim still in the relationship with the perpetrator?*YesNoIf no, when did the relationship end?* How many children are there?*Please enter a number from 0 to 15.Child(rens) age(s) (click + to add a child's age)* Has the victim been referred to the Athena (Refuge)?*YesNoPlease name the Athena caseworker* Does the family have recourse to public funds?YesNoWhat is the immigration status of the victim(s)?Asylum SeekerRefugee StatusHumanitarian protectionUASC leaveDiscretionary leaveLimited leave to remainIndefinite leave to remainVisaEuropean Union citizenHas the family been discussed at the DA Surgery before?YesNoIf yes, when? MM slash DD slash YYYY ALL CASE INFORMATION MUST BE ANONYMISED FOR THE PURPOSE OF DISCUSSION WITH EXTERNAL PROFESSIONALS. ANY SUBMISSIONS THAT CONTAIN PERSONAL IDENTIFIABLE INFORMATION WILL BE REJECTED.Details of Case*Please include current concerns, support/work already carried out and any behaviours you are concerned about regarding the children. Please anonymise your response and please limit your response to no more than 500 words.Client's Wishes*Please tell us why you are bringing this case to the DA Advisory Surgery and what outcomes the client wishes to achieve? Please anonymise your response and please limit your response to no more than 500 words.Select Date*25/03/21 - 4.00 pm - 4.30 pm25/03/21 - 4.30 pm - 5.00 pm25/03/21 - 5.00 pm - 5.30 pm25/03/21 - 5.30 pm - 6.00 pm22/04/21 - 4.00 pm - 4.30pm22/04/21 - 4.30pm - 5.00 pm22/04/21 - 5.00 pm - 5.30 pm22/04/21 - 5.30 pm - 6.00 pmDisclaimer* I agree by attending the Professionals Surgery that anything discussed will remain confidential unless we are worried about aspects of the case or that you, or someone close to, is at risk of harm. I also agree that all case information has been anonymised for the purpose of discussion with external professionals.NameThis field is for validation purposes and should be left unchanged.