ODAS/WBDAS

Referral and Assessment Form

If referral from outside agency please send to after completing Section 1

Section 1 (Referrer or Helpline)

Date: / Person completing Section 1:
Source of referral: / Contact details of referrer:
Client aware of referral: Y/N/Not known / Is client known to Adult Social Care? Y/N
Social worker’s name & contact details:
Language spoken:
Does client require Interpreter? Language Line needed?
Client name:
AKA: / Perpetrator’s name:
AKA:
What does he/she do? Where does he/she work?
D.O.B: / Perpetrator’s DOB:
Ethnicity: / Ethnicity:
Present Address:
Local Authority area: / Perpetrator’s Location (if different):
Previous Address:
Local Authority area:
Safe contact number: Safe time to call:
Safe to leave message: Y/N
National Insurance Number:
Recourse to Public Funds?Y/N
Indefinite leave to remain in the UK?Y/N
Details:
Children: / Pregnant:
Name & Surname / Gender / DOB / Living with client? / Perpetrators child?
Do any of the children have support needs?
Any social services involvement with the children? Y/N
Contact name & details:
The Disability Discrimination Act 1995 defines a disabled person as ‘a person who has or has had in the past a physical or mental impairment which has a substantial and long-term adverse effect on their ability to carry out normal day to day activities’
Under this definition would the client consider themselves to be disabled? / Y/N
Relationship with perpetrator:
Estimated date that abuse started:
Estimated length of relationship:
Summary of circumstances:
Police Involvement? Y/N Contact name and details:
Crime Reference number:
Bail Conditions:
Address Flagged? Y/N
Any other professionals involved? Contact name and details:
Support Needs: Drugs/Alcohol/Mental Health/ Complex Needs
Action taken:
Refuge: Y/N
(A risk assessment and background checks will need to be completed by our service before we are able to confirm that a space can be offered. Therefore, at this stage we cannot guarantee a space.)
Has client applied for refuge elsewhere? Y/N If yes, details:
Outreach: Y/N
Group Work: Y/N Please state which group
Helpline Support: Y/N
IDVA referral (pending decision) : Y/N
MARAC referral (pending decision) : Y/N
Any other sign posting:
Are you interested in the Freedom Programme? Y/N
RTK?
No of ticks on DASH/Checklist (if applicable):
Is client aware of MARAC referral? Y/N
Background and Risk issues: Begin with a summary of the most recent incident or an explanation of how this case was identified for referral to MARAC.
Type out all the yes factors with a yes tick on the dash form and include the comments given by the client for each of these questions. E.g. 1/Swollen stomach after being punched.
Why does the case require a multi-agency approach: This section is about risk management. Comment on any risk factors listed in the previous section that have already been addressed and are being risk managed. Identify those risk factors which still need to be addressed and if you have suggestions which MARAC agencies may be able to reduce these risks and what actions they may take then make a note of these.

Section 2: (To be completed by Access and Outreach)

Date: / person completing Section 2:
Next of Kin/Emergency Contact Details:
Name:
Address:
Phone No’s:
Relationship:
Is the Address:
Homeowner? / Sole JointNone
Private landlord? / Sole JointNone
RSL / Sole Joint None
Please state, which:
Contact name:
Do you need help securing separate housing for yourself/or to exclude the perpetrator? / Yes No
Plans for preferred housing options (refuge, privately rented etc)
Do you need legal advice: / Injunction:
Occupation order:
Contact:
Prohibited steps
Immigration / Y/N
Y/N
Y/N
Y/N
Y/N
Solicitors Details:
Are you in debt? / Y/N
What are the debts and how much?
Joint or sole debts?
Do you need assistance with debt management? / Y/N
Will you need support in identifying what benefits you may be entitled to? / Y/N
Do you have any substance misuse issues? Y/N Details:
Have you had past issues with drugs? Y/N Details:
Are you currently taking any prescribed or un-prescribed medication? Y/N
List of Medication and Dosage:
1.
2.
3.
4.
5.
Any Allergies? Y/N Details:
Do you have any alcohol misuse problems? Y/N Details:
Have there been any past issues? Y/N Details:
Please state any mental health problems, past or present and current treatment/support agencies:
GP Name:
GP Address:
Please state any criminal convictions:
Does the perpetrator have any links to the area?
How likely will the perpetrator try and look for you?
Have you been in refuge before?
If yes, when? / Where?
Make client aware of weekly service charge Y/N / Amount: £
Make client aware of refuge rules Y/N / State Rules

Section 3: (By Outreach Only)

Date: / Person completing Section 3:
Do you need to use the sanctuary scheme? / Y/N
Do you have the helpline number/24hr helpline number: / Y/N
Do you have a support network? Y/N Details:

Section 4 (Refuge Decision Making – Refuge Staff)

Staff signatures and date of staff involved in admission to refuge – should be 2 staff members. Box for summary of questions raised during admission meeting – please make sure safeguarding checks have been done before acceptance.
Accommodation offered Y/N (please make sure Safeguarding checks have been done before acceptance)
Give reasons and details if declined. (Service Manager/Team Leader approval must be gained in the event of any declines)
Summary of Questions raised during admission meeting:
Staff signatures – 2 members of staff to be involved with the admission into refuge
Staff Signature: / Date:
Staff Signature: / Date:
Manager/Team Leader signature (if declined):
Housing Management:
Tenancy Start Date:
UH Ref No:
Property Ref No:
Client Profile:
Height/ Description and any distinguishing feature (eg. Tattoos, birthmarks):
Vehicle Reg No:
Vehicle Make and Model:
Work:
Child/ren Profile: (Continue overleaf if more than 1 child)
Height/ Description and any distinguishing feature (eg. Tattoos, birthmarks):
Primary language:
School Attended:
Who has parental responsibility?
Who has residency/order?
Perpetrator Profile:
Height/ Description and any distinguishing feature (eg. Tattoos, birthmarks):
Vehicle Reg No:
Vehicle Make and Model:
Work:
Any other useful information:
Signed (Service User): / Date:
Signed (Person Completing Assessment): / Date:

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