WWCSC referral form

Step 1 of 5

SECTION A: REQUIRED INFORMATION ABOUT THE REFERRER and the FAMILY BEING REFERRED
REFERRER’S DETAILS
Date of Referral*
DD slash MM slash YYYY
Name of Professional making the referral*
Organisation / Team*
Telephone Number*
Email*

PARENT/CARER

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

CHILD (Please list all children in the family)

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

Use the plus button at the end of the line to add more children

Address and Postcode of Family*
Phone Number*

ANY OTHER SIGNIFICANT MEMBERS OF THE HOUSEHOLD OR FAMILY

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

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

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.

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.

ABOUT THE ABUSE
Risk level - today
Professional Judgement
DASH RIC Score
MARAC
If yes, please indicate outcomes from MARAC
Has any of the following been experienced?
- Physical Abuse
- Stalking / Harassment
- Financial Abuse
- Emotional Abuse
- Honour based violence
- Coercive control
- Sexual Abuse
- Psychological Abuse
- Forced marriage
Are they still in a relationship with the perpetrator of domestic abuse?
How long were they in a relationship with the abusive person?
When did the relationship end?
Does the perpetrator/alleged perpetrator still reside in the family home?
If no longer in the relationship with the alleged perpetrator, is the client currently in a new relationship?
Please detail how the child/children have been impacted by the abuse:
Please click Next to proceed
INFORMATION ABOUT THE PERPETRATOR/ALLEGED PERPETRATOR (IF KNOWN)
Name:
Relationship to Client:
Address:
Date of Birth:
MM slash DD slash YYYY
Does the perpetrator / alleged perpetrator have contact with the children?
Is there a non-molestation order in place?
Is there a prohibitive steps order in place?
Is the perpetrator/alleged perpetrator known to probation services?
Are there any licence/bail conditions or current proceedings taking place in relation to the Domestic Abuse?
If yes, please provide details:
If there is more than one alleged perpetrator, please provide additional details below:

SECTION D: FAIR PROCESSING AND CONSENT FORM
Here at Lewisham Children and Family Centres we take your privacy very seriously with your consent we will process, retain and store your personal data on behalf of the London Borough of Lewisham in line with the General Data Protection Regulation (GDPR) (EU) 2016/679. Your personal data and contact details will not be shared with any other third party or organisation but may be shared with other Children and Family Centres, and other partnership organisations. You have the following rights regarding your personal data: • The right to withdraw consent at any time • The right to request your personal data is deleted • The right to access to your personal data For more information regarding the use of your personal data please see www.lewishamcfc.org.uk or make a request to: Lewisham.Secure@eyalliance.org.uk or Early Years Alliance, Camelot Centre, 50 Meliot Road, London, SE6 1RY and a copy of the policy will be sent to you.
*
I understand that by providing my consent I am confirming I understand how and why my personal data is used and give permission for Lewisham Children and Family Centres to store and update my personal details.
*
I am a parent/legal guardian of a child/children under the age 16 and give consent for Lewisham and Children Family Centres to store and use my child/children’s personal data for the purposes of the service.
*
I give permission to Lewisham Children and Family Centres and any relevant partner organisation to contact me regarding services available and my access to them by:
Preferences
- Select All
- Email
- Post
- Telephone (including text messages)
PLEASE CONFIRM THAT THE PARENT HAS GIVEN VERBAL CONSENT FOR THIS REFERRAL. NOTE: A REFERRAL WILL NOT BE ACCEPTED WITHOUT EITHER WRITTEN OR VERBAL PARENTAL CONSENT*
VERBAL CONSENT HAS BEEN GIVEN
Date Consent Given:*
MM slash DD slash YYYY
REFERRER’S NAME:*
Please type name
Date:*
MM slash DD slash YYYY
Comments
This field is for validation purposes and should be left unchanged.

“My child and I have really enjoyed coming to Little Explorers. It has helped my child to get used to see other babies and have interaction with them, which has been really important for him after the pandemic.”

“It's absolutely fab to be able to have access to all of the Domestic Abuse services in one place and to just click on a link to get to the website.”

“The Children Centre is our favourite place to come, we have been coming here since my child was 6 months old, he is now 4 years old and is still enjoying! Well done staff”

“I have just found the ‘taking care of ourselves’ section, which is massively important for us all, especially compassion fatigue.”

“The help and support that my family support worker gave me was above and beyond, she was always there to listen to me and make me feel like I was good enough and I was being heard.”

“The Outreach Team have such outgoing, friendly and fun personalities and made each Outdoor Learning session a great experience.”

“The Explorers session has helped my child a lot with his communication and his development. It’s really been impactful for him; we are really grateful to have this opportunity to attend the session and meet other parents as well.”

“The sessions help my daughter with speaking English, as well as helping her to listen and follow directions. I am very happy, my baby is very happy, and I feel relief when I come.”

“The Children Centre is very beneficial for my child, she has developed lots of skills e.g., sharing toys and naming colours. Also, the staff are very friendly and helpful.”

Welcome to the Lewisham Children and Family Centre Website

WWCSC 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