Referral Form
Date of Referral *
Referred From *
Reason for Referral
Referrer Details
Name *
Address *
Telephone Number *
Email Address *
Job Title *
Client Details
Name *
Other Known Names
Address *
Post Code
D.O.B / Age *
Email Address
Telephone Number *
Ethnicity *
None
Afghani
African
Albanian
Algerian
Arabic
Azerbaijani
Bangladeshi
Black Caribbean
Brazilian
Caucasian
Chadian
Chinese
Columbian
Czech
Eastern European
Egyptian
Erritriean
Ethiopian
Filipino
Greek Cypriot
Grenadian
Gypsy/ Traveller
Hispanic
Indian
Indonesian
Iranian
Iraqi
Irish
Ivory Coast
Japanese
Kenyan
Kurdish
Latvian
Libyan
Malaysian
Mauritian
Mexican
Mixed - Black
Mixed - Mexican/White
Mixed - Middle Eastern
Mixed - Other
Mixed - South Asian
Moroccan
Nigerian
Pakistani
Palestinian
Peruvian
Polish
Romanian
Rwandan
Somalian
Spanish
Sri Lankan
Sudanese
Syrian
Tanzanian
Thai
Tunisian
Turk Cypriot
Turkish
Uzbekistani
Vietnamese
White British
White Caucasian
Yemeni
Gender *
Female
Male
Non-binary
Transgender
Not stated
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
None
Bisexual
Heterosexual
Lesbian / Gay
Other
Undisclosed
Religion
None
Atheism
Buddhism
Catholic
Christianity
Hinduism
Islam
Judaism
Not Stated
Other
Sikhism
Disability
(please specify)
None
ADHD
Autism
Learning Difficulties
Other
Physical Disability
Special needs
Marriage Status
Married
Single
Separated
Widowed
Divorced
Co-habiting
Not Stated
Marriage Details (if applicable)
Date of Marriage
Place of Marriage
Date you separated from your partner and/or left home
General Information
Any areas deemed a risk to you? *
Language Used *
None
Albanian
Amharic
Arabic
Bengali
Cantonese Chinese
Czech
Dari
English
Farsi
French
Gujrati
Hindi
Italian
Kurdish
Lingala
Malayalam
Mandarin Chinese
Mir Puri
Other
Pashto
Persian Daria
Potwari
Punjabi
Romanian
Spanish
Swahili
Tamil
Telugu
Urdu
Vietnamese
Interpreter Needed *
Yes
No
National Insurance Number
Employment Status
Employed
Unemployed – not looking for work
Unemployed – looking for work
Retired
Student
Not stated
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
Immigration Status
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?
Perpetrator Details (if applicable)
Perpetrator 1
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)
Perpetrator 2
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)
Children Details (if applicable)
Child 1 Details
Name
D.O.B / Age
Gender
Female
Male
Non-binary
Transgender
Not stated
Address
(if different)
Child 2 Details
Name
D.O.B / Age
Gender
Female
Male
Non-binary
Transgender
Not stated
Address
(if different)
Child 3 Details
Name
D.O.B / Age
Gender
Female
Male
Non-binary
Transgender
Not stated
Address
(if different)
Child 4 Details
Name
D.O.B / Age
Gender
Female
Male
Non-binary
Transgender
Not stated
Address
(if different)
Child 5 Details
Name
D.O.B / Age
Gender
Female
Male
Non-binary
Transgender
Not stated
Address
(if different)
Children Details (cont.)
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 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)
Details of Problem/Enquiry/Reason for Referral
CAADA-DASH Risk?
Yes
No
If yes, when was it completed?
If yes, what level was it?
Please select
High
Medium
Standard
Referred to MARAC?
Yes
No
Are you working with any other agencies at present?
(Yes / No - If 'Yes', please provide details)
Safe Person To Contact
Safe Person Name
Safe Person Address
Safe Person Contact Number
Relationship to Victim
Safe Word to Use
Risk Assessment — Refuge
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
What issues do you need support with?
Outreach Support
Safety Measure
Benefits Advice
Emotional Support
Legal Support
Mental Health
Accessing Services
Immigration Advice
Housing
Other
If 'Other', please specify
Client Authorisation
Client has authorised their case to be referred to the agency listed and, if applicable, any third party.
Authorisation Date
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