Date of Referral:
Consent gained? Yes No – consent required before processing
Referral for: 2nd stage accommodation Floating resettlement support
REFERRER’S DETAILS
Referral Agency:
Contact Name:
Position:
Address:
Telephone Number:
Email:
How long has this woman been with your service?
SERVICE USER’S DETAILS
Name: / Known As:
DOB: / Age:
Address:
Borough of Residence:
Type of accommodation:
Safe to post? /
Yes No
Tenancy status /
Length of time tenancy has been managed: /
Mobile No.: / Safe to call? / Y N
Safe to leave voicemails? / Y N
Safe to text? / Y N
Email Address:
Language: / Interpreter needed? / Y N
Nationality:
Immigration status:
Recourse to public funds? / Y
N
EEA
National Insurance No.:
Source of income:

EXPLOITATION EXPERIENCED

Which type of sexual exploitation has the woman experienced?
Trafficking into prostitution
Trafficking into other sexual exploitation
Prostitution On street: Off street:
Please give details of the nature of the exploitation experienced and NRM status if any:

RISKS AND SUPPORT NEEDS

Risk Assessment: / Details of risk to self:
Details of risk to others:
Details of risk from others:
Support needs: / Mental health needs
Physical health needs
Support needs resulting from a disability
Problematic Substance Use:
Alcohol Drugs Medication
Offending support needs
Please give details of the nature and effect of the support needs:

CHILDREN

Does the woman have children?
Y N
Is the woman pregnant?
Y N
Are the children subject to a child safeguarding process?
Y N
Does the woman live with her children? If not please explain including dates
Y N
Please give relevant details (i.e. CIN/CP plans and SWs details if known):

REASON FOR REFERRAL

Please provide as much information as possible regarding the needs of the service user, her reasons for wanting to access the project and what she hopes to gain from it.
Please outline your assessment of the service user’s suitability for the project describing the progress made by the SU over the period of support with your organisation and how this has prepared them for 2nd stage support.

Please complete demographics form below:

Gender: / Female Male Intersex Transgender
Gender Queer Other …………….
Ethnicity: / White:
White British White Irish White Traveller/Gypsy White Eastern European Other White European
Mixed/multiple ethnic background:
White and Black African White and Black Caribbean
White and Asian Other mixed/multiple ethnic background
Black:
Black African Black Caribbean Black British
Other Black ethnicity
Asian:
Asian British Asian Indian Asian Pakistani
Asian Bangladeshi Chinese Other Asian ethnicity
Other:
Arab Any other ethnic background …………….
Prefer not to say
Disability: / Blind or visual impairment Learning Disability Mental Health Mobility Other disability Prefer not to say
Deaf: / Deaf Hearing Impairment Prefer not to say
Relationship Status: / Single Separated In relationship Cohabiting
Civil Partnership Married Divorced Widowed
Other ……………. Prefer not to say
Religion: / No religion Muslim Christian Jewish Hindu
Buddhist Other ……………. Prefer not to say
Sexuality: / Heterosexual Gay Lesbian Bisexual Queer
Other ……………. Prefer not to say

Once we receive the referral we will acknowledge it and contact the referrer/service user within 5 working days to arrange an assessment.

Please call the Amari Project on 0203 874 5027 if you have any questions.