Fledglings

Consent to referral
Has consent been obtained from the non-abusing parent/guardian for this referral?*
- Yes
- No
If ‘No’, Safe Steps will be unable to contact the client

The person making the referral
Referrer's name*
Organisation name*
Role / Job title*
Contact number*
Contact email*
Eligibility criteria
I confirm the family has been impacted by DV*
- I confirm the family has been impacted by DV
I confirm the relationship has ended between AP and non-abusing parent / or CYP are no longer living in the household, for a minimum of 3 months*
- I confirm the relationship has ended between AP and non-abusing parent / or CYP are no longer living in the household, for a minimum of 3 months
Fledglings will not accept any referral where the relationship is ongoing or has not been separated for at least 3 months. (Unless children living elsewhere, as it does not meet our criteria as a post-separation recovery service)

Non-abusing Parent/Carer Contact Details
First name*
Last name*
What do they like to be called?
Date of Birth

Day
Month
Year
Phone number*
Safe to contact by phone? (including calls, texts and voicemails)*
- Yes
- No
- Don't know
Email address
Safe to contact by email?
- Yes
- No
- Don't know
Current address*
Street Address Address Line 2 City / Town County Postcode Country
Accommodation type*
Safe to contact by letter?
- Yes
- No
- Don't know
Next of kin – who can we contact in an emergency?
Name
Relationship to client
Contact information
Does the NOK know about the child's experience of domestic abuse?
- Yes
- No
Parent/Carer accessibility requirements
Does this client have any accessibility requirements (for example, hearing loop, braille documents)
- Yes
- No
If yes, please provide details
Does this client require an interpreter?
- Yes
- No
- Don't know
If yes or don't know, please provide further details

Alleged Perpetrator/s (AP) Details
Name*
First Last
Any other names
Date of Birth

Day
Month
Year
AP relationship to parent/carer*
AP relationship to child/ren*
Occupation (if known)
Current address / Last known address
Street Address Address Line 2 City / Town County Postcode Country
AP Notes – e.g. bail address, bail conditions, brief description, drug/alcohol issues, hobbies/interests of concern, known warning markers, military, use of weapons.
If there is more than one AP, please provide additional details in the box below:
Including full name, DOB / approx. age, relationship to the client and child/ren, current/last known address or area, occupation (if known), any concerns we need to be aware of.

Child/ren’s Details
CYP Details*
Forename Surname Date of Birth Gender Relation to AP (child / stepchild etc.) Who else has PR (name of individual if not AP) Nursery / School / College (inc. year group)

Child/ren’s and YP exposure and experience of Domestic Violence
Brief history of Domestic Abuse background*
Please include: - Duration of the relationship - What life was like for the client within the relationship - Examples of incident/s that happened (approx. dates/year it happened, where were the children during these, outcomes e.g. police or social care involvement) - Separation details (approx. dates/year, what led to separation e.g. any incidents), any escalation of abuse post-separation.
Current Situation*
Please include: - How much contact is there from AP/s since separation and now - Any on-going abuse post-separation (e.g. verbal, emotional, financial, coercive control, stalking/harassment), have these incidents been reported/logged, is the client currently receiving support around stalking/harassment?
Child Contact*
Please include: - Is there current contact between AP and CYP? - If contact; details of frequency/schedule, how long has this been in place and is this arrangement stuck to? - Any conflict about contact.
Court*
Please include: - Current or historic injunctions (including expiry date/approx. date/year) - Child Arrangement Order details.

Impact on Child/ren and YP
Please describe briefly the needs for each child
Physical Health
Please include: - Physical health disabilities - Allergies/Intolerances (are they prescribed medication/medical equipment e.g. EpiPen, asthma pump - how often are these needed to be taken) - Known as outpatient to clinics/hospitals - Historic/current sleep problems (e.g. insomnia, bedwetting, night terrors)
Emotional & Mental Health
Please include: - Diagnosed mental health conditions - Prescribed medication, how often are these needed to be taken - Any learning needs - Known to GP or under CAMHS (historic/current) - How does the CYP present (e.g. anxious, withdrawn, shy, aggressive) - CYP's self-esteem/confidence - Known to Lighthouse centre (historic/current) - CYP's feelings over what they have experienced/witnessed. - Any noted concerns from the client over CYP's well-being.
Relationship between siblings and extended family
Please include: - What the CYP's relationship is like with any siblings, grandparents, wider family members etc.
Education & Social Life
Please include: - CYP's school attendance and attainment - Any support in school (SENCO, pastoral care, counselling) - Relationship with peers - Known hobbies and interests.

How can we help you?

Forename	Surname	Date of Birth	Gender	Relation to AP (child / stepchild etc.)	Who else has PR (name of individual if not AP)	Nursery / School / College (inc. year group)