Our aim is to empower women across Angus to explore their options and make safe choices.

Cedar Online Referral Form

Date of Referral *

Referrer Information:

Referrer Name *

Organisation *

Address *

Postcode *

Telephone Number *

Relationship to Family *

Consent:
Has the family given consent for this referral?

yes

Child/Young Person's Information:

Name *

Date of Birth *

Address *

Postcode *

Telephone Number *

Ethnicity *

Name of main carer at the above address *

Relationship to Child/Young Person *

Who has parental rights/responsibilities? *

How many children live in the household? *

School *

Year/Class *

Contact Person at School *

Telephone Number *

Any additional support needs? *
(e.g. behaviour/learning needs, translator etc?)

Mother's Information:

Name *

Date of Birth *

Address (if different from above)

Postcode

Telephone Number *

Ethnicity *

Alongside the groups for children, the CEDAR Project also offers a group for the mothers of those children. The aim of the women's group is to help the mother to support her child to recover from their experiences of domestic abuse. Attendance of the mothers' group is not compulsory but is strongly recommended in order to ensure the child has the maximum support.

Is the mother interested in attending the women's group?

yes

If no, please indicate the reasons

Does the mother have any additional support needs?
Please specify:

Alternative Contact Details:

Alternative Contact Name *

Address *

Postcode *

Telephone Number *

Child Protection:

Does the child/young person have an allocated social worker?
If yes, give details:

Has there been any child protection issues?
If yes, give details:

Are any legal orders in place?
e.g. Child protection register etc?

Is the child/young person looked after and/or accommodated?
If yes, give details:

Has the child/young person previously been looked after/accommodated?
If yes, give details:

Are any of the following services involved? Please provide contact name and details:

Social Work

Health Visitor

Nursery

School

Police

CAMHS (Child Adolescent Mental Health Service)

Other

Background Information:

Information provided here will help the Cedar worker and family to decide whether the group might be appropriate for this child/young person at this time.

Brief family history

Child's memory of abuse?

Main reasons for referral to the Cedar programme

Perpetrators relationship to the family?

What contact arrangements are there between child/young person and perpetrator? Are there any legal arrangements for this?