BCC Form – Walk The Walk CIC

About the Child/Young Person

How many children/young people? *

Child/young person name *

First

Last

Date of birth *

List their full names and ages *

Any concerns we need to be aware of regarding the children/person *

Any allergies or disabilities or medical support needed: *

Is English the child/young person’s first language? *

Does the child have a very favourite toy or activity they enjoy? *

Any further Information

Details of Parents and Family Members

Resident parent name *

First

Last

Concerns or worries: *

Any allergies or disabilities or medical support needed: *

Home Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Telephone numbers (home and mobile if possible) *

Does this parent have parental responsibility? *

Email *

Non-resident parent name *

First

Last

Home address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Telephone numbers (home and mobile if possible) *

Does this parent have parental responsibility *

Email *

Where did you hear about us? *

Information About the Referral

Have you been informed that our service offers supported contact only? *

What is the type of contact you are requesting? *

Weekly
Fortnightly
Monthly

What is the contact length that you are requesting? *

Please specify the number of hours

What is most preferred? *

Week days
Weekends
Outside of school hours

Length of contact period requested *

1 month
6 months
1 year

Are there any dates that need to be avoided? *

Why is contact being requested? *

Is this the first contact centre that the family will be experiencing? *

Please provide feedback:

Are there any other Professionals working alongside the family? Please indicate all that apply.

CAFCASS
Social services
Health visitor
Domestic violence unit
Solicitor
CGL
CAMHS or adult mental health service
School

State any others not listed above

Essential Information Regarding Concerns/Risks

What potential risks are there to the child/young person during contact? *

Are there any risks or concerns that the Contact Centre should be aware of?

Do you have any concerns about your child/ren in relation to their safety or wellbeing?

Are there any concerns/risks around drug or alcohol abuse?

Who will be paying for the service? Please provide with full details of name and contact details, and where possible bank details.

Legal and Operational Information

Is the child subject to a Child Protection Plan? *

Under what category and why?

Is the child/young person subject to any court orders? Please detail if so. *

Are there any current legal proceedings affecting this child? Please detail, i.e court dates etc *

Is there anyone else permitted to attend? *

Please include full names and contact details (email & phone)

Is there anyone NOT permitted to attend? *

Please full names and contact details (email & phone) *

In the event this person attends, please confirm you understand and agree our measures (see below) *

If anyone not permitted arrives at the centre, staff from Bubba’s Contact Centre will ask them to leave. If they do not do so, we will inform them that we will contact Hertfordshire Constabulary. If they continue to remain, we will contact 999. Please confirm that you have understood and agreed to these measures.

Please state your reason for selecting "No". Bubba’s Contact Centre reserves the right to stop or decline a referral if processes are not adhered to in the safety of the children and the Centre staff. *

Are the parents aware of the child’s current address? *

Are parents/carers permitted to meet? (please specify) *

Are any of the below court ordered? *

To give the child/young person money during contact
Give sweets to the child/young person
Provide food
Take the child/young person out of the centre
Give presents, toys etc
Photographs of the family
Take photographs
Video the child/young person
Use mobile phone for self
Permit child/young person to use mobile phone
Give child/young person letters/cards from family members

For parents with parental responsibility unless court ordered we are unable to stop any of the below.

Please detail any of those selected above.

Information We Collect

In order to provide our services we collect and process Personal Data from the users of our Contact Centre.

We collect your information from

Referral Forms
Referrals from organisations e.g. Cafcass, Family Solicitors
Pre visit checklist

We may also collect information from telephone conversations, emails and written and verbal communications and from records of the Contact Centre sessions.

We collect the following information

Personal information (for example, your name, email address, mailing address, phone numbers, date of birth and address)

Sensitive Personal Data

Attendance information (such a attended, number of absences and absence reasons)

Safeguarding incidents

Report Sheets

Chronology of contact, communications, phone calls. This is a working document and will be shared with parents, solicitors etc prior to court hearings.

From time to time and as permitted by applicable law(s), we may collect Personal Data about you and update any existing Personal Data that we currently hold from other third-party sources

Your Personal Data may be used in the following ways:

To provide our services to you,
To respond to your requests and inquiries,
To improve our services
To comply with applicable law(s) (for example, to comply with a search warrant or court order) or to carry out professional ethics/conduct investigations,
To enable us to provide, to maintain our own accounts and records and to support and manage our employees.

Consent and lawful Processing of data.

Our legitimate interests, which include processing such Personal Data for the purposes of

providing and enhancing the provision of our services.
administration and programme delivery
for dealing with medical needs-any information you provide we must have had explicit consent to use.
all other cases: that it is necessary for our legitimate interests which are to run the contact centre

The full policy is available on request. Please sign to show you have read and understood. Thank you