Stockport Without Abuse – Referral Form

*(Read out to applicant) Please be aware that if you tell us you are

concerned about the welfare of yourself, another person or a child,

we have a duty toinform the relevant agency in order to protect

their safety*

Personal Information

Name: / Date:
Date of birth: / National Insurance number:
*Compulsory for applicants born outside the uk
Ethnicity: / Tel:
*Safe to contact?:
Do you consider yourself to have a disability? If so, please provide details:
Next of Kin:
Tel:
Address:
Referring Agency:
Contact name: / Number:
Address:
Reason for referral (current situation which has prompted the referral):
Name of abuser: / Date of birth:
Relationship to abuser:
Address:
What type of Abuse have you experienced?
Length of relationship: / When abuse started:

Safety Issues

Are you currently at risk from the abuser? Yes  No 

Does the abuser live at the above address with you?Yes  No 
Does he/she know your address?Yes  No 
Has he/she been to your present address? Yes  No 
*If you are offered accommodation with SWA we will contact you to make arrangements for you to make your way to the refuge. If we are unable to contact you after several attempts we may contact the police and give them your address to carry out a check of your welfare. If you would prefer that we do not take this action please indicate below (please tick one box).
Contact police in event of no contact 
Do not contact police in event of no contact 

As a referring agency, will you be providing any support whilst this woman/ family are accommodated at SWA?

Current address you are fleeing:
Date left previous address:
Salary/ Income

Do you work? If yes, part-time or full time?

Place of employment:
If not employed, how do you support yourself?
For non-UK residents you must provide written evidence that the applicant has recourse to public funds in order for them to make a claim for benefits, including Housing Benefit. Without this, the application will not be assessed.
SWA staff member to confirm that written proof has been provided for the following:
‘Indefinite leave to remain’ ‘Recourse to Public Funds’
Yes  No  Yes  No 
If you answered no to any of the above, please give details below, eg leave to remain until what date? How is the applicant supporting herself?
Are you in receipt of benefits (Yes/No)?
Benefits: / Amount & frequency
Reason for disability/ Incapacity benefit:
Explain rent to applicant: £171.98 per week total rent. If in receipt of full benefits, service charge will be £13.00
Explain Housing Benefit eligibility criteria.

Have you lived in a Refuge/ Hostel before? Please give details

Address History for past 2 years:

Previous Address: / Landlord:
Address:
Tenancy from:
Tenancy to: / Contact name:
Reason for leaving:
Previous Address: / Landlord:
Address:
Tenancy from:
Tenancy to: / Contact name:
Reason for leaving:
Previous Address: / Landlord:
Address:
Tenancy from:
Tenancy to: / Contact name:
Reason for leaving:
Do you have a local connection to Stockport? Eg have you lived in Stockport
How did you hear about SWA?
Do you have/ have you had any convictions for any offences?

Support Needs (Ask sensitively)

Please provide the following information to enable us to provide the most appropriate service for you and to see if we can meet your needs.
Yes/No
/
Details
Do you require an interpreter? / Language:
Do you have any mobility requirements?
Can you read and write in English?
Do you have any cultural or faith needs?
Do you have an informal support network?
Do you have any pets?
Do you have any illnesses?
Do you have a diagnosed mental health illness?
Do you take any medication?
Do you have a history of overdosing or attempting suicide? /
Do you/have you in the past physically self-harmed?
Do you have any other concerns in regard to your emotional well being?
Do you/have you recently used illegal drugs?
Are you on a methadone programme?
Do you use alcohol regularly?
Have you ever committed a serious offence?
Do you pose a risk to staff or members of the wider community?
Do you have a record of offences against children?
Is there anything important you would like to add?

Do you have/ is there any other agency involved with you or your family? (Eg Social Services/ Health Visitor). Please give details:

Agency / Tick / Contact Person / Contact Details
Social Services
Immigration Agency
Probation
Health Visitor
Housing Officer
Mental Health Worker
Alcohol Agency
Drugs Agency
Domestic Violence Officer
Doctor
Solicitor/Legal service
Victim Support
Age concern
Manchester City Council
Any other support agency

NB Our local area of Social Services will not accept case responsibility until your client is re-housed within the area. This also applies to Community Mental Health services.

Dependants

Are you pregnant?
Do you have any children you wish to be accommodated with you?

Names

/

DOB/ Age

/

Gender

Are there any presenting problems associated with the above children?
(Special Needs, Behavioural problems, etc)
Do you have any other children who are not accommodated with you?

NAMES

/ D.O.B./AGE / GENDER / REASON
Are any of the above children, including those not accommodated with you, subject to a Care Order?
If so, what is the reason for the Care Order?

Do you require assistance in any area of child care?

Data Protection Declaration

In accordance with the Data Protection Act 1998, I agree that the agencies listed in this referral may be contacted and information shared with SWA in support of my referral, accommodation and support.

Due to the health and safety implications for staff and service users of SWA, we may be unable to offer a service unless this declaration has been signed.
Signature of applicant…………………………………… Date:………………………

1

\\Server\main share\Refuge\Refuge Forms\Referral pack\Refuge Referral Part 1.doc Feb 2013