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A Father's Child Services CIC

Community Support

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Refer To Us

Referral Form

If you are human, leave this field blank.

Referring Organisation/Person (Enter N/A if not applicable) *

First Name: *

Last Name: *

Please specify your gender? *

Please specify your Ethnicity? *

Please confirm your age? E.G 24 *

Date of Birth: *

Do you give us consent to store and use your information in line with GDPR/Data Protection Principles to provide our services? *

Yes

No

Phone No: *

Mobile Phone No:

Email *

Address 1: *

Address 2: *

Address 3:

Town/City: *

Postcode: *

A Father's child Services CIC Services. What service are you making a referral to? *

Counselling

Mentoring

Workshops

The Therapy Hub

Other programmes when funding is available

How would you like us to contact you? E.G. Phone, text, Email other *

How did you become aware of the service? *

Do you have any other support in place? E.G. Social Worker, another organisation *

Yes

No

If Yes, please provide more information *

Circumstances we should be aware of, E.G. NEET (Not in Employment, Education or Training) *

Yes

No

If Yes, please provide more information. E.G. How long, any other issues *

Tell us what support you think could help? *

Have you ever used A Father's child Services CIC services? *

Yes

No

Has anyone related to you/affiliated with you used A Father's child Services CIC services? *

Yes

No

If so, do you know the name of the Practitioner that supported them?

Do you know anyone that works at A Father's child Services CIC? *

Yes

No

If so who?

How enthusiastic are you/the person you are referring with wanting to make change? Use the below scale *

1-2 Stuck

3-4 Accepting Help

5-6 Motivated and Taking Responsibility

7-8 Learning what works

9-10 Self Reliant

Do you class your self as being affiliated with a gang? *

Yes

No

If so, what area/s are you associated with? E.G B19, B21

URGENT INFORMATION ABOUT THIS YOU THINK WE SHOULD KNOW (Enter N/A if nothing applies) *

Other please specify? E.G. Domestic Violence/Grooming? (Enter N/A if nothing applies) *

Please describe what may be worrying you. (Enter N/A if nothing applies) *

Have you been experiencing Low Moods? *

Yes

No

If so How Long?

E.G. 2 weeks, more than a month.

Self Harming Thoughts/Behaviours *

Yes

No

Suicidal Thoughts/Feelings? *

Yes

No

Worries around behaviours with Food *

Yes

No

Have you spoken to anyone about how you are feeling? *

Yes

No

Other

If Yes or other, Please state who? *

Have you or anyone in your household suffered from Covid-19, Flu like symptoms or a temperature or been in contact with someone that has in the past 21 days? *

If yes, have you been tested? *

Yes

No

Mental Heath First Aid at Work

Supporting Mental Health in the workplace

Clean Business by Catch Themes

The National Lottery Community Fund - Government Response

A Father’s Child Services CIC has now secured Funding from the
Coronavirus Community Support Fund, which is distributed by The National Lottery Community Fund,
for us to deliver some much needed Mentoring, Mental Health First Aid Training and provide Psycho-educational Resources
In response to Covid-19.

See Our Projects Here!
You can make an online Referral on our ‘Contact Us‘ Page or through our ‘Refer to Us Page’

Anyone can make a referral for our Mentoring,*Workshops & *Counselling Services, including G.P’s, Support Workers, or Self-Referrals.
We have a range of options for Children, Young People, Families and Adults.
Supporting with Adult & Youth Mental Health, General Well-Being,
Gangs, Employment Support, Victims of Domestic Violence or other Crimes.
Click the above Links to make a Referral!
*Currently NO funding for these services

We are also currently working in conjunction with The Birmingham Children’s Partnership (BCP)
to deliver the last of the Counselling & Mentoring funded as part of the COVID-19 response project.
So we do not have the funding for new referrals from this project.
Special Thanks to The BCP for the much needed resources for the Community!