REFERRAL FORM

date received …………………………………REFERRING AGENCY…………………………..….………

nAME ……………………………………………… . telephone number ……………………………………

NOTE: Verbal agreement must be obtained from the client for an agency to make a referral

IF SELF REFERRAL, HOW DID YOU HEAR ABOUT THE SERVICE? ......

REQUEST FOR: OUTREACHWDWRNDWRWDSH

PATTERN CHANGINGRECOVERY TOOL KIT

CLIENT DETAILS
Name:
Alias(es):
Title: Gender:
Date of Birth: Age:
Current Address:.
Postcode:
Address fled from:
(If different)
Postcode
National Insurance no:
Email:
Telephone number: . Mobile:
Will anyone else answer these phones?
Is it safe to leave a message/text?
What times are best to call?
Children
Name of child 1: Date of Birth
Name of child 2: Date of Birth
Name of child 3 Date of Birth
Other people living or staying at the address:
Additional needs of the children named above
Any Social Services involvement either current or historic (if yes - details - including area, phone number, named social worker, ICPC, Safeguarding)
REFERRAL INFORMATION
Brief Description of client’s current situation: (DV History, Police involvement, CAADA DASH, health needs, drug and alcohol issues, housing needs, disabilities etc – please use additional pages if necessary)
MARAC/MAPPA/IDAP History:
Court Dates:.
Any Injunctions:
Are you currently responsible for any property ie current tenancy, licence, mortgage?
Have you been accepted on any housing register?
Any local connection?
Employment status
Economic status
Recourse to public funds (benefits)
Have you stayed in a refuge before (if yes - where, dates, why did they leave)
Perpetrator Details:
Name:
Aliases :
Date of Birth:
Relationship to Client:
Current Address:
Last known address
Description
Car Details(make, model,colour etc)
ETHNIC ORIGIN OF APPLICANT (please tick)
a. White British Irish Other
b. Mixed White & Black African White & Black Caribbean
 White & Asian  Other
c. Asian/Asian British Indian  Pakistani  Bangladeshi
 Other
d. Black/Black British Caribbean  African  Other
e. Chinese or Chinese  Other ethnic group
ethnic group Gypsy / Traveller
f. Refused 

Does the client identify as being any of the following:

Learning Disability Physical DisabilityRefugee / Asylum seeker

HIV/AIDS HomelessMental Health 

Offending Behaviour Rough Sleeper  Gypsy / Traveller

(if yes, please detail)


Risk Assessment

Disclosure of any of the following information will not exclude the applicant from accessing the service. It is important that all questions are answered to the best of your knowledge.

Do you have any current issues/history of…

Drug Abuse

Alcohol Abuse

Arson

Mental Health

Aggression/Violence

Sexual Offence

Involvement with the criminal justice system

Any other agency/policeinvolvement

I have read the completed referral form and can verify the information on it.

Client
Signature
Print Name
Date
Person completing the referral
Signature
Print Name
Date
You first worker completing the referral
Signature
Print Name
Date
Data Protection Statement (please read to the client)
By submitting this referral form to you first, you agree to our processing your personal information in order to assess your housing needs and manage and develop any services we provide for you or negotiate on your behalf.
If you are offered a place at one of our refuges or safe houses we may need to pass your information to the relevant landlord - Raglan Housing Association/Spectrum/East Borough Housing Association (delete as required), although we only do this on the understanding they keep the information confidential.
We may also disclose your information if we have a duty to do so, or if the law allows us to.
As data controller, we will not keep your information longer than necessary and will strive to keep it up to date. You have the right, under the Data Protection Act 1998, to see and if necessary, correct personal data we hold about you.
Outcome/Refuge space/Outreach offered:
If refused/declined, signposted to: