Referral Form

Date of Referral * Referred From *

Reason for Referral

Name * Address * Telephone Number * Email Address * Job Title *

Name * Other Known Names Address * Post Code D.O.B / Age * Email Address Telephone Number * Ethnicity * Gender *

Which or these contact methods are safe to use? * Postal Email Text Home Mobile

Is it safe to leave voicemail message/text? * Yes No

Sexuality Religion Disability (please specify) Marriage Status

Date of Marriage Place of Marriage Date you separated from your partner and/or left home

Any areas deemed a risk to you? * Language Used *

Interpreter Needed * Yes No

National Insurance Number Employment Status Name and Address of Employer (if employed)

Do you receive benefits? Yes No

If benefits are received, which benefits are you in receipt of? Are there any issues with mental health, alcohol, drugs, learning disability? (If yes, please provide details) GP Name GP Address Contact Number

Indefinite Leave to Remain * Yes No Unknown

Recourse to Public Funds Yes No

Refugee / Asylum Seeker? (If yes, please specify date of entry to UK) Details of Passport / Visa If no funding, can client fund themselves or can another agency fund them to stay in safehouse/refuge?

Name D.O.B / Age Address Current Risk from Perpetrator? Does the perpetrator have any history of violence or criminal record? (Yes / No - If yes, please provide details) Does the perpetrator have any criminal convictions? (Yes / No - If yes, please provide details) Is there any known issues with mental health, alcohol or drugs? (Yes / No - If yes, please provide details)

Name D.O.B / Age Gender Address (if different)

Are you pregnant? Yes No

If yes, when are you due?

Was a child present at the incident? Yes No

Did the child witness the incident? Yes No

Were any injuries sustained? (If yes, please provide details)

School Name School Address School Telephone Number CAF Completed? (Yes / No - If yes, please provide details) CP or CIN? (Yes / No - If yes, please provide details)

CAADA-DASH Risk? Yes No

If yes, when was it completed? If yes, what level was it?

Referred to MARAC? Yes No

Are you working with any other agencies at present? (Yes / No - If 'Yes', please provide details)

Safe Person Name Safe Person Address Safe Person Contact Number Relationship to Victim Safe Word to Use

Does client have any convictions, pending convictions or being investigated by police? (Yes / No - If yes, please provide details) Does client have any history of self-harm? (Yes / No - If yes, please provide details) Has the client been in a refuge previously? (Yes / No - If yes, please provide details) Has the client been evicted from a refuge or service previously? (Yes / No - If yes, please provide details) Are there any indicators to suggest the perpetrator would follow the client to the refuge? (Yes / No - If yes, please provide details) Does the client have any family connections in the Cleveland area? (Yes / No - If yes, please provide details) Please advise of any additional relevant information If 'Other', please specify

Client has authorised their case to be referred to the agency listed and, if applicable, any third party. Authorisation Date

Referral Form

Referrer Details

Client Details

Marriage Details (if applicable)

General Information

Immigration Status

Perpetrator Details (if applicable)

Perpetrator 1

Perpetrator 2

Children Details (if applicable)

Child 1 Details

Child 2 Details

Child 3 Details

Child 4 Details

Child 5 Details

Children Details (cont.)

School Details

Details of Problem/Enquiry/Reason for Referral

Safe Person To Contact

Risk Assessment — Refuge

Client Authorisation