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ROYAL BOROUGH OF KINGSTON MARAC REFERRAL FORM

MARAC referrals must be emailed to:

Professionals from within Kingston Council and AfC mail service can email securely to

If you do not have access to secure email please call 0208 5475040

Please read the following information before making a referral
Information within this referral will be shared with the MARAC Partnership, which includes Kingston Council, health providers, probation services, domestic violence specialist agencies, housing providers, police, drug and alcohol services, children’s services and education services. Information is shared to a limited group of professionals for the purpose of increasing protection around the victim and any children, and is only shared beyond this membership where it is believed to be in their best interests to do so. Information for clients about the MARAC process is available at www.Kingston.gov.uk/MARAC
The client must understand who their information is to be shared with in order to give informed consent to this referral. However, in some circumstances it may be safer not to inform the client that you are making a referral to MARAC.
If the client does not consent to the MARAC referral, including where you have decided it is safer not to request that consent, you must complete the “information shared without consent form” at Annex A to refer the case. To discuss consent or information sharing, call MARAC Coordination on 020 8547 5040.
Does the client consent to this referral to MARAC?
If you answer no you must complete the form at Annex A
Referred By
Name
Position
Referring Agency
Date of Referral
Telephone Number
Email Address
Victim / (please duplicate this box for each victim) /
Name (SURNAME in capitals)
Dob
Ethnic Origin
Language (state if client requires an interpreter)
Address
Housing type (if RSL state
which if possible)
Contact Telephone No.
Safe to leave message
Mental Health Issues
Drink/Drugs Issues
Disability (Please state)
GP details
Sexual Orientation
Occupation (please include
whether the victim feels safe at work)
Children (add extra lines as necessary) / Complete if known
Name and address / Dob / Relationship to perpetrator / Social worker / School
Do you believe that there are risks facing the children in the family?
Note: Witnessing or hearing domestic violence harms a child.
If you have answered yes to the previous question, a referral must be made to Children’s Safeguarding. What date did you make this referral?
Notes:
Perpetrator 1 / (please duplicate this box for each perpetrator) /
Name (SURNAME in capitals)
Dob (approx age if no dob)
Ethnic Origin
Relationship to victim
Address
Mental Health Issues
Drink/Drugs Issues
Occupation
Car registration
Any Other Information

Referral Details

Reasons for Referral – please complete either A or B below
A: Reason for referral – new cases
Please TICK ONE of the below 5 options as your reason for considering the referral high risk
1)  POTENTIAL ESCALATION: There have been 3 or more domestic violence incidents by the same perpetrator on the same victim/survivor in the last 12 months and they are increasing in severity or frequency; or
2)  VISIBLE HIGH RISK: You have completed a DASH Risk indicator checklist (RIC) with the victim/survivor and they scored 14 or more yes ticks (the RIC is at the end of this form. Please complete this or send the RIC separately if you consent for it to be forward to the DV hub); OR
3)  PROFESSIONAL JUDGEMENT: You as a professional consider the victim/survivor to be high risk (at risk of serious harm or death). Please take into consideration the victim/survivor’s own perception of risk.
4)  SUSPECTED HONOUR BASED VIOLENCE: Automatic referral
5)  CHILD TO PARENT VIOLENCE: There have been three or more incidents in the last 12 months and/or the incidents are increasing in severity or frequency
B: Reason for referral – repeat cases (already flagged as a MARAC case/heard at MARAC within the last 12 months)
REPEATS: If the victim/survivor has been referred to the MARAC in the last 12 months and there has been at least one further DV incident by the same perpetrator on the same victim/survivor since the referral. A Repeat incident is any of the below incidents (whether or not they have been reported to Police)
1)  Violence or threats of violence to the victim (including threats against property); OR
2)  A pattern of stalking or harassment OR
3)  Rape or sexual abuse
Date of repeat incident: / Type of incident (1,2 or 3)
CURRENT RISKS TO THE VICTIM (BASIS OF REFERRAL)
Include the date of the recent DV disclosure or incident that led to the referral to the MARAC
KEY HISTORICAL INFORMATION
Historical information that increases the risk (think patterns of behaviour, previous breaches of orders)
Is there any other relevant information (from victim or professional) which may increase risk levels?
Consider victim’s situation in relation to disability, substance misuse, mental health issues, cultural /language barriers, ‘honour’-based systems, geographic isolation and minimisation. Are they willing to engage with your service?
Consider abuser’s occupation /interests. Could this give them unique access to weapons? Describe.
What are the victim’s greatest priorities to address their safety?
What risk management is in place between now and the MARAC meeting?
Please ensure that you complete RIC attached to this sheet, or send a RIC PDF with the referral. If you have not risk assessed the case or have not attached the RIC, please say why below

Please attach or complete risk assessment

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SAFELIVES DASH Risk Identification Checklist (RIC)

If you are not familiar with the DASH, you must read the DASH with guidance. You can find this by googling “Safelives DASH with guidance” or clicking here.

Points to note:

·  Your professional judgement is key – results from a checklist are not a definitive assessment of risk. They should provide you with a structure to inform your judgement and act as a prompt to further questioning, analysis and risk management. If you identify risk but are not sure of how best to proceed, contact the DV Hub on 020 8547 6046.

·  This form is not a full risk assessment for children. The presence of children increases the wider risks of DV and step-children are particularly at risk. If risk towards children is highlighted you should consider what referral you need to make to obtain a full assessment of the children’s situation.

Before you begin

·  Establish how much time the victim has to talk to you. Is it safe to talk now? What are safe contact details?

·  Establish the whereabouts of the perpetrator and children

·  Explain that the purpose of asking these questions is for the safety and protection of the individual concerned

/ Yes / No / Don’t know / State source of info if not the victim /
1.  Has the current incident resulted in injury? State what and whether this is the first injury.
2.  Are you very frightened?
Comment:
3.  What are you afraid of? Is it further injury or violence? Please give indication of what you think (name of abusers(s)…) might do and to whom, including children.
Comment:
4.  Do you feel isolated from family/friends i.e. does (…) try to stop you from seeing friends/family/doctor or others?
Comment:
5.  Are you feeling depressed or having suicidal thoughts?
6.  Have you separated or tried to separate from (…) within the past year?
7.  Is there conflict over child contact?
8.  Does (…) constantly text, call, contact, follow, stalk or harass you? Please expand to identify what and whether you believe that this is done deliberately to intimidate you? Consider the context and behaviour of what is being done.
9.  Are you pregnant or have you recently had a baby (within the last 18 months)?
10.  Is the abuse happening more often?
11.  Is the abuse getting worse?
12.  Does (…) try to control everything you do and/or are they excessively jealous? In terms of relationships, who you see, being ‘policed at home’, telling you what to wear for example. Consider ‘honour’-based violence and specify behaviour.
Comment:
13.  Has (…) ever used weapons or object to hurt you?
14.  Has (…) ever threatened to kill you or someone else and you believed them? If yes, tick who
You Children Other (specify who)
15.  Has (…) ever attempted to strange/ choke / suffocate / drown you?
16.  Does (…) do or say things of a sexual nature that make you feel bad or that physically hurt you or someone else? If someone else, specify who
17.  Is there any other person who has threatened you or who you are afraid of? If yes, please specify whom and why. Consider extended family if HBV
18.  Do you know if (…) has hurt anyone else? Please specify whom including the children, siblings or elderly relatives. Consider HBV
Children Another family member Someone from a previous relationship Other (please specify)
19.  Has (…) ever mistreated an animal or the family pet?
20.  Are there any financial issues? For example, are you dependent on (…) for money/ have they recently lost their job / other financial issues?
21.  Has (…) had problems in the past year with drugs (prescription or other), alcohol or mental health leading to problems in leading a normal life? If yes, please specify which and give relevant details if known
Drugs Alcohol Mental Health
Comment:
22.  Has (…) ever threatened or attempted suicide?
23.  Has (…) ever broken bail/an injunction and/or formal agreement for when they can see you and/or the children? You may wish to consider this in relation to an ex-partner of the perpetrator if relevant
Bail conditions Non-Molestation/ Occupation Order Child Contact arrangements Forced Marriage Protection Order Other
24.  Do you know if (…) has ever been in trouble with the police or has a criminal history? If yes please specify
DV Sexual violence Other violence Other
Total ‘yes’ responses

Practice note: The full DASH RIC contains questions re: access to weapons and other risks. These questions appear in part A of this referral therefore are not duplicated here.

Safelives DASH RIC

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Annex A - Information sharing without consent form

Consider what risks you are hoping to reduce by sharing information without consent. If you are making a referral through an automatic criteria, consider whether in your professional judgement there is a risk of harm to the parties involved.

Who is at Risk? / Immediate risk/crisis / Risk identified through risk assessment
Risk/danger to child(ren)
Risk/Danger to survivor
Risk/Danger to Vulnerable Adult
Client poses a risk to self or others

Legal Authority to Share

This section must be completed for this case to be heard at MARAC without consent

Legal grounds (If yes, please tick one or more grounds below) / Y / N
Tick all that apply
Child protection – disclosure to social services or police for the exercise of functions under the children act, where the public interest in safeguarding the child’s welfare overrides the need to keep the information confidential (DPA, sch 2 & 3)
Prevention / detection or crime and/or apprehension or prosecution of offenders (DPA, sch 29)
To protect vital interests of the data subject; serious harm or matter of life or death (DPS, sch 2 & 3)
For the administration of justice (usually bringing perpetrators to justice (DPA, sch 2 & 3)
For the exercise of functions conferred on any person by or under any enactment (police / Social Services) (DPA, sch 2 & 3)
In accordance with a court order
Local Authority Enquiry under Care Act 2014
Prevention of abuse and neglect The Care Act 2014
Overriding public interest (common law)
Right to life (Human Rights Act, art. 2 & 3)
Right to be free from torture, of inhuman or degrading treatment (Human Rights Act, art. 2 & 3)
Add name here to confirm you have considered the legal grounds to share this information
Manager oversight provided by (name)

Safelives DASH RIC