Lamplight API response

Your age range

Your gender

Your marital status

Your sexual orientation

Your ethinicity

Your employment status

Which county do you live in (Required)

Do you have a long standing illness, disability or infirmity? (Long standing refers to anything that has troubled you over a long period of time, or is likely to affect you over a period of time)

Parents Preferred Email Address (Required)

Please confirm you consent to being contacted by email (Required)

Family details (at home)

Please give details of members of household - please add names, ages and relationship to parent (Required)

Does the child/ren displaying behaviours live with you currently? (Required)

If the child presenting the behaviours does not live with you, how often do you have contact with them?

How long has the family been experiencing child to parent abuse? (Required)

Child/Children displaying abusive behaviours

Age of Child/Children displaying behaviours (Required)

Gender of child displaying behaviours (Required)

If more than one child displaying behaviours please record their gender/s here

Your parental responsibility (Required)

Is there Drugs/Alcohol/Substance misuse?

Has there been any Physical/Emotional trauma?

Have they been a witness to/Victim of Domestic Abuse?

Are you fearful of your child/children? (Required)

Is the behaviour of your child having an impact on your physical or mental health?

Have you needed to contact the police due to your child/children's behaviour?

When was the last time the police were contacted (if known)?

Childs abusive behaviours (Select the frequency of each behaviour)

Verbal (Required)

If verbal: are there threats to harm?

If verbal: are there threats to kill?

Please give examples of the Verbal Abuse:

Physical/Violent (Required)

Has your child attempted to or used any objects as weapons or actual weapons to cause harm?

If Physical: have you had to get medical treatment because of this behaviour?

Please give examples of the Physical Abuse:

When was the last physical incident? (month/year)

Control/coercive (Required)

Does the child make any false allegations?

Please give examples of the Coercive / Control behaviours:

Sexualised Behaviours and Language(Required)

Please give examples of the Sexualised Behaviours and Language:

Financial control- This could include demanding money or things you cannot afford, effects on employment or stealing money (Required)

Please give examples of the Financial Control:

Damage to Property (Required)

Please give examples of the Damage to Property:

Digital Abuse - This could include monitoring, stalking, harassment, threats or control using technology. (Required)

Please give examples of the Digital Abuse

Does the child/ren harm any pets or animals?

Do you have any other support services involved with the family?

Referring professional details (Parents do not need to complete this section)

Professional full name

Professional role

Professional organisation

Professional email address

Professional Telephone No

Has parent given consent for this referral (IF NOT 'YES' we will not proceed with your referral)

Please confirm that you understand that the referral is for the parent/guardian and not for the child

Information of the Referral

Please give a brief summary of your current situation and the impact it is having on you (Required)

Consent for PEGS (you MUST give PEGS consent for us to proceed)

Do you consent to PEGS storing your personal data (Required)

Do you consent to PEGS processing your personal data (Required)

Do you consent to PEGS sharing your personal data with other agencies (Required)

Whilst we will not share your information without your consent, if a safeguarding referral is needed we are obliged to report this to the necessary authorities. Please confirm you understand this statement.

Do we have consent to call the Parent, Carer or Guardian?

Do we have consent to text the Parent, Carer or Guardian?

Please select the date this consent was given (Required)

Preferred Contact Days

Monday

Tuesday

Wednesday

Thursday

Friday

Preferred Contact Times

9:30-12:00

12:00-3:00

3:00-4:30