PAC-UK | One Adoption Referral Form

One Adoption Referral Form

Only complete the below referral form if you are a social worker or professional working in One Adoption North & Humber, One Adoption West Yorkshire or One Adoption South Yorkshire.

If you have any questions prior to completing the form, please contact PAC-UK's Advice Line on 0300 1800 090 or email oneadoption@pac-uk.org

PAC-UK is the lead provider in a service (funded by One Adoption) working with 15 Local Authorities to provide support to anyone in the region affected by adoption.

Please include as much detail as possible on the referral form below. Fields highlighted with a red * symbol are mandatory and must be completed in order for you to submit the form.

Once you have pressed submit, your form will automatically be sent to the PAC-UK Advice Line who will respond at the earliest possible opportunity. A notification message will appear on your screen confirming your referral has been received and you will receive a copy of your form via email.

All information processed in relation to your enquiry and/or booking adheres to PAC-UK's Privacy Statement.

Note, failure to provide enough information could result in delays. Please read each question carefully to ensure all contact details provided are correct.

One Adoption Referral Form

Referring Local Authority /Agency

Name of referring Local Authority /Agency

If your referring local authority is not listed in the below dropdown menu please contact the PAC-UK Advice Line by phone on 0113 230 2100 or email referrals@pac-uk.org prior to completing this referral form. If you are making a One Adoption referral please visit www.pac-uk.org/oneadoption to be redirected to the correct referral form.

Referring Social Worker /Professional

Name of referring Social Worker /Professional

First

Last

Office number of referring Social Worker /Professional

Mobile number of referring Social Worker /Professional

Email of referring Social Worker /Professional

Would you like us to add your email address to our PAC-UK Training and Newsletter mailing list?

Yes

All our PAC-UK mailouts include 'unsubscribe' options.

Office address of referring Social Worker /Professional

Address Line 1

Address Line 2

Address Line 3

City

Postcode

Details of person being referred

Can the person being referred be contacted directly by PAC-UK?

Yes

Is the person being referred a birth parent who has had a child adopted within the past three years?

Yes (tick and also add date of adoption if known)Yes (tick and also add date of adoption if known)

Unsure

One Adoption ask PAC-UK to report on this information - please complete accurately. Note for PAC-UK staff processing this referral, ‘Date of Adoption’ must be entered on the Client Connection screen after adding ‘Adopted Child’ as a ‘Service User Contact.’

Title

Name of person being referred

First

Last

Landline number of person being referred

Mobile number of person being referred

Email of person being referred

Address of person being referred

Address Line 1

Address Line 2

Address Line 3

City

Postcode

Local Authority

Placing Local Authority (if applicable)

Date of Birth

Gender

Sexual Orientation

Ethnic Origin

Religion

Does the person/s being referred have any known neurodiversity considerations?

This should include anyone listed in 'other household members' and 'details of children' sections of this form.

If yes, please provide details

Does the person/s being referred have any form of disability?

This should include anyone listed in 'other household members' and 'details of children' sections of this form.

If yes, please provide details

Name/s of other household members

Title of other household member

Name/s of other household members

First

Last

Landline of household member/s

Mobile number of household member/s

Email of household member/s

Date of Birth

Gender

Sexual Orientation

Ethnic Origin

Details of child/ren

Full Name (Child 1)

First

Last

Date of Birth ( Child 1)

Whereabouts of Child 1

Full Name (Child 2)

First

Last

Date of Birth ( Child 2)

Whereabouts of Child 2

Full Name (Child 3)

First

Last

Date of Birth ( Child 3)

Whereabouts of Child 3

Any other information

Please add any other relevant supporting information here, including any additional children.

Adoption details of person receiving service (if applicable)

Birth Name

First

Last

Adopted Name

First

Last

Date of Adoption

Location of Adoption Records

Reasons for referral

Details of referral

Services required

Safeguarding or contact issues

Please advise us of any safeguarding or contact issues. It is important that this information is provided from the outset to enable planning of our services.

Any other information /issues

Please list any other information or issues we should be aware of at this stage here.

File Upload

Maximum file size: 16.78MB

If you would like to send supporting documents with this referral please upload here before pressing the 'Submit' button.

File Upload

Maximum file size: 16.78MB

If you would like to send supporting documents with this referral please upload here before pressing the 'Submit' button.

File Upload

Maximum file size: 16.78MB

If you would like to send supporting documents with this referral please upload here before pressing the 'Submit' button.

If you are human, leave this field blank.