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The Bridgeway Referral Form

Please fill form as fully as possible; any gaps please respondUnknown (U)

The Bridgeway offers a number of services for people affected by sexual assault and abuse and is operated by several organisations working in partnership so the service user gets as seamless a service as possible. When you obtain consent from the person for a referral to The Bridgeway, you should check that they consent to receive services from Birchall Trust, G4S Forensic- Medical Services, Safety Net and Victim Support, as relevant to them. Please provide details of what consent has been given in the relevant section below.

Client Details
Client name
Age and DOB
Address
Postcode / Is it safe to visit? Yes/No
Contact Details (mobile/landline/email)
Preferred method of contact / landline mobile post email
Is it safe to leave a message? Yes / No
Homeless / no fixed abode?
Gender / Male / Female
Next of Kin/Emergency Contact Details
Preferred Method of Contact / Landline Mobile Post Email
Is it safe to leave a message? Yes/No
Referral Agency
Date of referral
Referrer name and contact details
Reason for referral / Sexual Violence / Sexual Abuse / Domestic Violence /
Other:
Has the client consented to the referral? / Yes / No
If No why?
Incident Number
Date of most recent incident
Has it been reported to Police? / Yes / No
Name of Police Officer involved:
What support is the client looking for?
What kind of support are you referring the client for?
Brief details of incident
Suspect details (If Known)
Name
Age and DOB
Relationship to client
Address if known
Gender / Male / Female
Dependants
Are there any children who have contact with or live with the client? / Yes / No
Name of child/children
Ages and DOB
Name of school
Is the child/children subject to: / Early Help LAC Section 17 Section 47
Name and contact details of Social Worker if applicable
Are there any vulnerable adults who live with or have contact with the client? / Yes / No
Name of vulnerable adult/s
Age and DOB

Mental Health Concerns / History

Any current mental health issues? / Yes / No
Any previous mental health issues? / Yes / No
Any self-harm / self-injuries? / Yes / No
Details and date of most recent
Suicidal ideation? / Yes / No
Details
Suicide attempts? / Yes / No accidental / deliberate
Details and date of last attempt

Physical Health Concerns/History

Is the client on any medication? / Yes / No
Name and daily amount
Alcohol Misuse? / Yes / No
Details of type and daily amount
Drug Misuse? / Yes / No
Name, amount and how used
Physical disability / illness? / Yes / No
Details
Learning Disability? / Yes /No
Details
Could the client be pregnant? / Yes / No
If yes, how far on?
Is the client in need of sexual health services? / Yes / No

Other

Is client at risk of domestic violence at home? / Yes /No
If Yes, please complete DASH Risk Assessment
Is client at risk of sexual violence at home? / Yes / No
Is client at risk of stalking or harassment? / Yes /No
Is client at risk of trafficking or sexual exploitation? / Yes / No
Is client at risk of child sexual exploitation? / Yes / No
If Yes, follow the LSCB CSE Procedures
Is client at risk of ‘honour based’ violence or forced marriage? / Yes / No
Is the client engaging in sex work? / Yes / No
Are there any other risk issues that the client is aware of? / Yes / No
Details
Name of GP
GP Address

Details of other agencies involved or referrals have been made to including:

Early Help / MARAC / Children’s Services

Agency

Contact Name

Contact Number

Date of Referral

Outcome

______

Action taken

______

Signature ______

Date ______

Please send this form via either of the following email addresses:

Email: /

Once referral has been sent please call 01768 800670/ 01768 800671 to confirm receipt

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