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Supported Referral Form

Wherever possible this form needs to be seen and completed by both parties’ solicitors and any other professionals involved with the family. Contact cannot commence until this form has been completed in full and received by the Centre Coordinator. All information will be treated in the strictest confidence.

1. Child

Please fill the following questions with information about one child, if there is more than one child involved then complete another form or call us.


2. Adult requesting contact





3. Adult with whom the child reside

4. Referrer

5. CAFCASS, Contact Orders & Contact








6. Arrival at the Child Contact Centre






Write the name of the other people allowed to participate in contact at the Centre.
Write the names as such: John Smith : Uncle, Adam Jones : Grandfather

7. Information Relating to Safety of the Child

If yes please give details


If yes please give details


If yes please give details



Please give details of any allegations, undertakings, injunctions or convictions relating to violence involving either party, their respective families or the children.

8. Health & Medical Requirements

If yes please give details


If yes please give details

9. Additional Information


If yes please give details of the interpreter, including name and organisation if any

Additional background information (Please state if there are any drug, alcohol or mental health concerns).

10. Accept terms and Conditions

Before you submit the form you must accept our Privacy Policy and our Data Protection Policy or visit our GDPR page by clicking the following checkbox.

I have read and accept the terms and conditions.*

Thank you for taking the time to complete this form.

The centre co-ordinator will shortly contact you to discuss the date you will start using the centre. The start date is will normally be within 1-2 weeks of receiving this completed form from each party. Please ask the other party to also complete a separate version of this form as soon as possible (if they have not already done so).

Once you have both submitted a completed form, we will call you both to book an intake session with you. This can take place over the phone or at the centre. Please note that you will be asked to pay the session fee in advance of your use of the contact centre and we will send you a payment link for the fee, you call us or pay by online banking to: Prime Time Charity, NatWest Bank, s/c 50-10-29, acc. 2166 1553.

If you are both not agreed about using the centre or who will be present during the child contact, then please click the button below to book an appointment with Family Mediation Services. Legal Aid for mediation is available for you if you are on a low income.

Fees for Supported contact are:
Unwaged or welfare benefits: £2.50 per hour
Unwaged with solicitors or waged: £7.50 per hour


Fees for Supervised contact are:
Unwaged or welfare benefits: £12.50 per hour
Unwaged with solicitors or waged: £17.50 per hour


Click here to make a referral to mediation if you are not yet agreed on if and how you will use a contact centre: Referral to Mediation

Contact Us

Prime Time Child Contact Centre

Rye Lane Baptist Chapel,
59A Rye Lane, Peckham,
London, SE15 5EX

Go to Google Maps

0300 365 2700

referral@ptccc.org.uk

“Keeping children in touch with parents following separation”