Referral to Alana House

Referral to Alana House

Women’s Community Project

The aim of Alana House is to offer support to local women with support needs and for those at risk of offending. We offer a holistic package including one-to-one support with a keyworker, groupwork activities and access to other local support services within a safe, female-only environment.

Support may be carried out as part of outreach in a mutually convenientneutral venuenear the service-user’s home, or atthe Alana House.

Name (of person whom support is for)
Address
Is it ok to contact the individual at this address?
Yes / No (delete as appropriate) / Alternative contact address:
Contact telephone number
Date of Birth
CRN number (if appropriate):
Disability / If yes does your disability require us to make any reasonable adjustment to accommodate your visit to the Centre?
YES / NO

In signing this form you agree that the information contained within can be held on file at Alana House and Alana House will contact you to book an Induction.

Signature of client / Date
Name of referring agent / Date
Job title / relationship of referring agent / Have you discussed this referral with the applicant? / Yes / No
(delete as required)
Address of referring agent
Contact number of referring agent: / Email address of referring agent:

Presenting Needs - Please tell us why you would like support from Alana House

(Tick the relevant box below & give a brief summary):

Accommodation
Education, Training Employment
Health (including Mental Health
Drugs & Alcohol
Finance, Debt & Benefits
Children & Families
Attitudes, Thinking & Behavior
Experience with DV, Abuse and Rape
Sex Working
Not Stated
Access only

Ethnicity: (please tick)

White British / White & Black Caribbean / British Pakistani
White Irish / White & Black African / British Indian
Other White British / White & Asian / British Bangladeshi
British Caribbean / Other mixed / British Chinese
British African / Not Stated / Other British Asian
Other Ethnicity (please state):

Risk Assessment: We need to ask about any risks that we need to address when working with service users. This will allow us to think about the best way to support each individual safely. Please include details of any history of self-harm, violent or threatening behaviour, risks to staff & substance misuse and details about how any identified risk is being managed?

Risk To: / Risk Level:
Known Adult / Low/Medium/High
The public / Low/Medium/High
Children / Low/Medium/High
Staff / Low/Medium/High
Themselves / Low/Medium/High
Risk Details:

If risk is medium or high please state why in Risk Details

Current criminal proceedings:

Please tick the relevant box below if this is a Probation or CJS referral:

Pre-court disposals / Conditional caution
Other pre-court disposal
Awaiting court hearing / Awaiting sentence/trial (not remanded or on bail)
On bail
Remanded in custody
Sentenced / Fine
Serving Community Order
Serving Suspended Sentence Order
On license
In custody - sentence under 12 months
In custody - sentence 12 months or more
Other sentence
Post sentence / Released from custody - not on license
Other post sentence
Not Known
Risk Screening attached: / Yes/No (delete as required) / License attached: / Yes/No/NA (delete as required)
Risk assessment attached / Yes/No (delete as required) / PSR attached: / Yes/No (delete as required)
Bail Conditional/Conditional Cautioning Referral: Yes/No/NA (delete as required)
Sentence Plan: / Yes/No(delete as required)……. If No state due date:

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