Referral Form

TOPAZ Therapeutic Life Story Practice Referral Form CONFIDENTIAL

Please fully complete this form and return by Secure Email to:

l_hassaine@hotmail.co.uk or topaz24@hotmail.co.uk

Or by Registered post to: Topaz, Lucia Hassaine, 8 Marefield Road, Marlow, Bucks SL7 2QE

Website: Topaz1.webnode.page

Child's Name:

Date of Birth:

Gender:

Parents/Carers Name and Address:

Telephone:

Email:

Child's Address (if different):

Referrers Name and Address:

Telephone:

Email:

Family Status (please circle as appropriate): Both Parents Lone Parent Step Carer

Is the child subject to a Child Protection Plan? Yes No Category:

Is the child a 'Looked after child'? Yes No Type of placement:

Is the child an adopted child? Yes No Number of years with present family

Childs School:

Telephone: Email:

Teachers name: School Year:

IMPORTANT NOTES: Please read and sign the following section to confirm agreement.

The TLSW sessions will normally take place in the child's family home.

Below is a map of the area I am able to cover.

Outside of this area, I am able to offer on-line TLSW sessions, or alternatively I can apply for ASGSF funding to provide the TLSW sessions in a studio in Marlow, town centre.
In certain circumstances the sessions may take place in the child's school.
Information about TLSW is outlined in the following websites:

https://tlswi.com/about-tlswi/

About Topaz :: Topaz1 Topaz1

If required, I am able to provide, free of charge, a preliminary on-line meeting with the parents, to explain the processes involved in the TLSW, prior to the application to ASGSF.
It is expected that the TLSW sessions will commence promptly at the start date.
The TLSW sessions will take place weekly, for one hour.
There are 15 TLSW sessions with the child and parent and an Initial, Midway and Final evaluation meeting with the parent/s.
It is expected that the parents and the child are prepared to commit to undertaking the 15 consecutive TLSW sessions, and 3 Evaluation meetings, on the start date, prior to the referrer applying for funding.
An important aspect of the Rose Model of TLSW is the inclusion and participation of the parent in the TLSW. The parent is expected to attend all the sessions with the child.
A Midway and Final review will take place with the parent and the Referring Social Worker.
Parents are encouraged to provide feedback of the progress of the sessions and raise any issues as they arise.
The following documents will be required prior to the commencement of the TLSW, where possible:

Assessment of Need form, Original Life Story Book, CPR, Later Life Letter, Chronology, other life history documentation and photos, reports from other therapeutic interventions, CAMHs reports, other health or development documentation.

It will not be possible to undertake LA file searches.

I reserve the right to decline to undertake any piece of TLSW where:
The child's /family history documents are not made available to me.
The family are not able to commence with the TLSW promptly at the start date.
The parents exhibit aggressive or insulting behaviour
It is expected that the work should be completed within 4 months, or 5 months at the latest (weekly sessions), therefore, please note…..
24 hour's notice is required from the parents to cancel a session, except in the case of unexpected sickness of the child, or for any other unexpected reason, at my discretion, to avoid forfeit of the session.
Frequent cancellations either with or without 24 hour's notice may result in the session/s being forfeited, and the withdrawal of my services to deliver TLSW to the child.

Please sign this section to confirm agreement.

…………………………………………Signature of Referring Social Worker

Please answer these questions as fully as possible-

Has the Parent/ Primary Carer received information and advice about TLSW? Yes No

Please explain:

Has the Parent/Primary Carer expressed any concerns or reservations about TLSW? Yes No

Please explain:

Has the child received any Life Story Work Yes No

Approximate date:

Was the Life Story Work a positive experience? Yes No

Does the child have a Life Story Book? Yes No

Does the child read the Life Story Book? Yes No

Does the parent/ primary carer read the Life Story Book with the child? Yes No

Will the child require a new/updated Life Story Book following this TLSW? Yes No

Does the child have any contact with birth parents, birth family or siblings? Yes No

Is the child aware of any aspect of their life history? Yes No

Please explain:

Please describe any special/additional needs:

Please describe the nature of any concerning behaviour:

What do you think is the cause of the behaviour? :

What are your /the parents expectations as a result of the child receiving Therapeutic Life Story Work? :

Are there any issues with regards to Parent-Child Attachment?

Will the family require Parent-Child Attachment sessions as part of the TLSW process? This involves a series of support sessions by telephone/virtual meeting with the parent/primary carer & practitioner and a series of weekly 30 minutes play sessions the parent & child undertake together.

Please provide a brief outline of the child's life journey so far:

Signed…………………………………………………………………………………………..Date……………………………………………

Please Print Name………………………………………………………………………..Job Title:……………………………………