Intermediary Service Referral Form

Section 1: Personal Details

Your name(Required)

First Last

Your full address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Your phone number(Required)

Your email address

Your preferred method of initial contact from PAC-UK:(Required)

Phone or Email

Phone

Your residential local authority(Required)

This is the local authority where you live. If you are unsure of your local authority you can check by entering your postcode on this website: www.gov.uk/find-local-council

Section 2: About You

You are(Required)

An adult adoptee (over 18)

A birth parent (a parent who has lost a child/ren to adoption)

A birth sibling (someone who has lost a brother or sister to adoption)

Other

To the best of your knowledge, when did the adoption take place?(Required)

1976 or earlier

1977-2005

2006 or later

Do not know

If you are an adult adoptee (over 18) have you already accessed your adoption records?

Yes

Unsure

If 'yes' when did you access your adoption records (approximate date is fine)?

What is your relationship to the person you are seeking to find?(Required)

I am their birth child

I am their birth parent

I am their birth sibling

Other

If you currently have any support in place or are working with any agencies that we should be aware of, please provide details below:

Section 3: Accessing Intermediary Services

Intermediary Services include support in searching for, approaching and reconnecting with relatives separated by adoption where contact is wanted. Your answers in this section will help us to offer you the right service to best meet your needs and determine whether any services could be fully or part funded.

Some new Intermediary Services grants have been made available by Adoption England for those affected by adoptions that took place in 1976 or earlier. Because we don’t know how many people will express an interest in accessing these new grants we may need to prioritise this funding using the following criteria; age, life threatening condition, income and whether an intermediary service has been received before.

When paying privately, Intermediary Services can typically range from £800-£2,000 depending on which registered provider you use and the level of service required – based on this price range, can you afford to pay privately for your own service?(Required)

Yes

Are you aged 70 or over?(Required)

Yes

Is the person you are seeking over 70?(Required)

Yes

Do you have a life threatening condition?(Required)

Yes

Tell us more about your life threatening condition(Required)

Do you receive means tested benefits?(Required)

Yes

Have you received an intermediary service to contact this person before?(Required)

Yes

If 'yes' how long ago was this and what was the result?

Have you ever been refused an intermediary service in the past?(Required)

Yes

If you are affected by an adoption that took place in 1976 or earlier and are interested in applying for grant funding, is your preference to receive an Intermediary Service from:

PAC-UK

Another registered intermediary provider

A list of registered intermediary providers can be found on the Adoption Directory page of the FamilyConnect website: www.familyconnect.org.uk/adoption-directory

Section 4: Equality Monitoring Information

We ask for this information to help us understand who is accessing our services and to ensure they are inclusive and accessible. Providing this information is voluntary and will not affect the support you receive – all answer choices include a ‘prefer not to say’ option.

Gender

Trans identity

Sexual orientation

Ethnic group

Religion

Disabilities and/or long-term health condition

If yes, please provide details

Neurodiversity considerations

If yes, please provide details

Thank you for completing this referral form. We will contact you as soon as we are able to with details about the services available to you, what to expect, the support we offer and any applicable costs.

We do appreciate that completing this form may have been triggering and difficult for you – please do contact our FamilyConnect Advice Line if you need to speak to someone about your situation.