Reviewed Nov 2012

REFERRAL FORM

MEN’S DOMESTIC VIOLENCE SERVICE (MEN’S PROGRAMME)

Email : Tel : 0845 602 7440 Fax: 01429 268 600

This form should be completed in conjunction with Harbour’s Referral Guidelines.

1. The REFERRER

Agency / Address of Agency (inc postcode)
Tel Number / Job Title of Referrer
Name of Referrer / Email Address of Referrer
Is the person aware you are making a referral? / Y N / Date of Referral
How did you find out about Harbour? / Saw Literature Recommendation Other, Details :

2. PERSONAL DETAILS OF THE PERSON REQUIRING THE SERVICE

Name / Other Known Names
Date of Birth / Tel. Number
Ethnic Origin :
(please tick) / White-
White British / Black or Black British- Caribbean / Asian or Asian British- Pakistani / Asian or Asian British- Other / Mixed-
White and Black Caribbean / Other Ethnic Group-Other
White-
White Irish / Black or Black British- African / Asian or Asian British- Bangladeshi / Mixed-White and Asian / Other Mixed Background / Prefer not to say
White-
White Other / Black or Black British- Other / Asian or Asian British- Indian / Mixed- White and Black African / Other Ethnic Group-
Chinese
Address / Postcode
Is the current address:
(Please tick) / Registered Social Landlord, please state : / Private Landlord / Owner / Occupier / Friends/ Family / Other, please specify
Emergency Contact Information (inc address, postcode and telephone numbers)
Has a referral been made to another agency? If yes, please give details. / Y N / Details :
Preferred Group Work area / Hartlepool Middlesbrough
Stockton Redcar and Cleveland / Any special needs/or disabilities?

3. PERSONAL DETAILS OF THE CURRENT OR EX PARTNER

Name / Telephone Number
Address, including Post Code / Date of Birth

4. SIGNIFICANT FAMILY MEMBERS

Name / Surname / Other Known Names / Gender / Date of Birth / Relationship to Client / Ethnicity / Any special needs?
Please continue on another sheet of paper if necessary.

5.PREVIOUS INVOLVEMENT WITH HARBOUR

Does the person have any previous involvement with Chrysalis or Harbour? If yes, give details. / Y N / Details :
Any family member have/has any previous involvement with Harbour? If yes, give details. / Y N / Details :

6. KEY AGENCIES WORKING WITH THE FAMILY

Name / Address / Telephone Number
GP
Police
Social Services
Probation
Addictive Behaviours
Mental Health
Other
Other
Other
Please continue on another sheet of paper if necessary.

7. OTHER INFORMATION

Are there Child Protection or Child in Need Issues? If yes, give details. / Y N / Details :
Are there any other secondary issues? (eg mental health, dependencies, disabilities, special needs) If yes, give details. / Y N / Details :
Any family members have/has been looked after by a Local Authority? If yes, give details. / Y N / Details :
Any family members have/has been on a disability register? If yes, give details. / Y N / Details :
Has there been any MAPPA meetings? If yes, give details. / Y N / Details :

Reason for Referral and Relevant Background Information

Please add details of any police call outs and domestic abuse convictions

8. CONFIRMATION

I CONFIRM THAT THE REFERRAL GUIDELINES HAVE BEEN READ AND UNDERSTOOD AND THAT THE DETAILS GIVEN ARE ACCURATE. I UNDERSTAND THAT ANY FALSE INFORMATION OR OMISSIONS MAY RESULT IN ANY OFFERS OF SERVICE WITHDRAWN.

Signature of referrer / Date

This section is completed by Harbour staff.

9. DECISION ON REFERRAL

RE/04BHarbour – Referral – Men’s Domestic Violence Service (Men’s Group Work Programme)Page 1 of 3

Reviewed Nov 2012

Referral taken by
Time/date of decision / Date Entered on Database / By Who?

RE/04BHarbour – Referral – Men’s Domestic Violence Service (Men’s Group Work Programme)Page 1 of 3

Reviewed September 2012

Is the referral accepted? If no, give details. / Y N
How and when was feedback given?
Date of First Contact
Signature of Worker
Date
Notes:

RE/04B Harbour – Referral Form – Men’s Service (Perpetrator) Page 1 of 3