Referral number: ____
Initial referral form for Beth Centre services for all Lambeth Women
The Beth Centre will provide an intensive, holistic support service to women
Date:Member of staff taking referral: ______
Substance misuse
Prison link
Young Women
Gang and violence
Peer support
Parenting support
Exiting Prostitution (LEA Pan-London)
Referrer’s Details
Referrer Name/Title
Referring Agency:
Referrer Telephone No:
Referrer Address:
(including borough)
Referrer email:
We may require further information from other agencies; can we have your permission to contact them if so?
Yes No
Service User Details
First Name: / D.O.B.
Last name: / Tel/Email:
Address: / Safe Contact details:
Postcode: / Borough
Preferred method of contact / email
telephone/mobile
post
Immigration status
Disability / Physical (please outline)……………………….
………………………….
………………………….
Learning Disability(please outline)…………..
………………………….
………………………….
Criminal Justice Involvement / Most Recent Conviction Date: / /
Offence committed:
Outcome (e.g. no further action / suspended sentence) :
Sentence Length:
Date Incarceration:
Release Date:
Details of Dependant Children and Vulnerable Adults:
Names / Gender / D.O.B./Age
Male Female
Male Female
Ethnicity & Cultural Details *
Asian
Bangladeshi
British
Indian
Pakistani
Other
Black
African
British
Caribbean
Other / Other
Chinese
Latin American
Middle Eastern
Mixed race
White
British
Irish
European
Other / Not Obtained
Refused to state
In no condition to ask
Unable to Choose
Interpreter Required: / Yes No / First Language:
Recourse to Public Funds / Yes
No
Not Sure
Sexuality / Bisexual
Heterosexual
Lesbian
Transgendered
Other
Prefer not to state
Religious Beliefs / Agnostic
Atheist
Baha’i
Buddhist
Christian
Hindu
Humanist
Jain / Jewish
Muslim
Rastafarian
Sikh
Zoroastrian
None
Other
Prefer not to state
Financial Situation: *
Studying Full time Part time On Benefits
Working Full time Part time
Please state which:
Experiences of Violence
Domestic Violence
Physical
Emotional
Sexual
Psychological
Financial
Reported? / Sexual violence
Childhood sexual violence
Adult sexual violence
Involvement in sex
industry
Reported? / Other violence
Genital cutting
‘Honour’ violence
Anti Social Harassment
Stalking
Perpetrated violence
Gang related violence
Reported?
Risk Assessment
1. Do you have a history of mental illness?(include dates) Yes No
…………………………………………………………………………
……………………………………………………………......
………………………………………………………………………...
Do you have a diagnosis? Yes No
…………………………………………………………………………
Are you on medication? Yes No
…………………………………………………………………………
Do you have a CPN and/or linked with the Community Mental Health Team?
(contact details)…………………………………………………………………………………. Yes No
…………………………………………………………………………..
…………………………………………………………………………..
2. If No, do you have concerns about your about your current Yes No
Mental Health?......
…………………………………………………………………………..
…………………………………………………………………………..
3. Have you ever self-harmed or have feelings of self-harm? Yes No
(Include dates)……………………………………………………………………………………..
…………………………………………………………………………..
4. Have you ever attempted suicide or have feelings of suicidal Yes No
Ideation?(include dates)......
…………………………………………………………………………...
……………………………………………………………………………
5. Do you have any physical health problems including blood Yes No
borne viruses?......
…………………………………………………………………………….
6. Do you have concerns about your current drug or alcohol use? Yes No
…………………………………………………………………………….
…………………………………………………………………………….
…………………………………………………………………………….
If yes, does the service user currently have a support worker around the drug and/or alcohol misuse problems?(contact details)...... Yes No
……………………………………………………………………………..
……………………………………………………………………………..
…………………………………………………
7. Have you or any member of your family, including children, had any threats of harm or to your life?...... Yes No
……………………………………………………………………………...
………………………………………………………………………………
8. Are there any danger areas for you that we need to be aware of? Yes No
(state borough)………………………………………………………………………..
………………………………………………………………………………
Reason for Referral: Please provide as much information as possible.
Referral email, fax and telephone:
Email:
Fax: 020 7820 8907
Telephone duty line: 020 7840 6700
Internal use: list follow up work (including appointments, workshops and accessing other services internally/externallyDate entered on database:______
Date full needs assessment completed______
Consent form signed ______
Date initial exiting plan agreed______
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