POCAR Referral Form

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Page 1

The overall aims of POCAR are:

  1. Support parents to address drug and alcohol difficulties to achieve their                   parenting goals.
  2. Enhance safety and stability for children.
  3. To increase parents’ self-esteem and confidence.
  4. Reduce isolation and build resilience.
Please note we aim to contact the parent within 2 weeks of receiving this referral.

Page 2

Parent details (We will use these to contact the parent. Please complete a separate referral if referring more than one parent or carer – POCAR has separate programs for men and women)

If the exact date is unknown, please give your best estimate.

Page 3

Children’s details (We need these to understand the family and for our safeguarding procedures. We will not contact the children or any carers without further discussion and consent)

Individual child

Please help us build a picture of the family by providing the following information about current family circumstances:

Pen Picture for the children – briefly outline important information relevant to this referral.

Page 4

Pen Picture for the adults – please provide brief details as a starting point to help us understand the parent’s experiences leading to this referral. Guiding questions in Italics.

Page 5

Briefly summarise what will help us start working effectively with this family, understand priorities and agree timeframes for goals.