Shine safe@homeReferral Form

Please complete details ONLY where information is known!

SECTION ONE: Referrer Details
Referrer: / Referral date:
Agency: / Initial Contact
Date:
Phone:
email:
Brief victim/offender history and reason for Shine safe@home referral.

PART ONE: VICTIM AND CHILD

SECTION TWO: Victim Details
First Name / DOB / Age
Last Name / Ethnicity / Gender
Street / Suburb
City / Home Ph
Email / Mobile
Risk Score / Interpreter required / Yes No
Property Ownership: / Housing NZ Corp Private Rental Own Home
Does victim have a current partner? If yes, record name and dob.
Protection Order / Yes No Applying for…
If Yes, date/location / Lawyer
SECTION THREE: Child Details
First name / Last Name / DOB / Age / F/M / Ethnicity / Relationship to offender
Parenting Order: Yes No Applying for…
Details of any child access arrangements?
Does anyone else live in the home and who are they?
Total number of residents in the home:
Disability Status of residents: Does anyone living in the home have difficulties as a result of :
a physical disability YES NO – details
a head injuryYES NO – details
otherYES NO – details
SECTION FOUR: Victim Employment/Income Status
Please circle:
Employed fulltime Employed part-time Unemployed Student Beneficiary
If employed, what occupation?
What are the days, hours worked?
SECTION FIVE: Victim’s Health Information
Is the victim pregnant? / No Yes, due date:
Suburb
City
Does the victim have any mental health issues? / No Yes, details:
Does the victim have any drug or alcohol issues? / No Yes, details:
Does the victim have any other significant
health issues? / No Yes, details:
SECTION SIX: Agencies Involved
Is this family known to CYFs? / Yes No / Is it an open case? / Yes No
Name of organisation / contact person, phone & email / type of involvement
Child, Youth & Family

PART TWO: OFFENDER

SECTION SEVEN: Offender Details
First Name / Last Name
aka / Ethnicity
DOB / Gender / PRN
Employment/ Income Status:
Employed fulltime Employed part-time Unemployed Student Beneficiary N/A
Occupation:
Has carpentry or DIY skills?
SECTION EIGHT: Victim / Offender Relationship
Victim’s Relationship to Offender: (define eg expartner, mother, sister)
How long was the victim with the offender? / Date of separation:
What ages were the victim and offender when they met?
Record of Most Recent Incident:
Seriousness rating of 1 to 5 as per Jacqui Campbell scale; 6 = psychological;
Date / Police Involved (Y/N) / Arrested (Y/N) / Seriousness – 1, 2, 3, 4, 5, 6,
Police RS

PART THREE: Shine safe@home Advocate to Complete

Offender Type: / Obsessed Sadistic Hyper-violent Other:
Lethality Risk Factors:
Separation
Child Access Disputes
Pregnancy/new birth
Escalation of abuse
Cultural issues
Alcohol and drug abuse / Stalking
Sexual Assault
Choking/Strangling
Verbal threats to kill
Verbal threats to commit suicide / Access to weapons
Unemployment
Violence/disrespect for the law
Mental health problems
Jealousy
REFERRAL Accepted or Declined – tick as appropriate:
Accepted
Victim lives/associates with offender Victim unable to be contacted
Victim declined the service Low safety concerns
Property unsuitable Victim went to refuge/other housing
Safety risk too great Victim living/moving out of area
No landlord consent Other