How to Complete This Referral

Crossroads Derbyshire Referral Form

Referral to Freedom Programme

How to complete this referral:

By completing this referral form, you’re helping us to make contact with the client as safely and quickly as possible. We’d appreciate it if you could include as much information as possible - this saves the client from being asked the same questions twice and helps us to understand more about their particular needs and circumstances.

This form is to be used for referrals in to:

The Freedom Programme

How to submit this referral:

Email to:

(Secure email)

Call: Derbyshire domestic abuse helpline 0800 019 8668 (press option 2 for High Peak)

You will receive a response within 48 hours

How to get in touch:

If you have any questions about our service, eligibility criteria, or how to make a referral, please contact 01457 856675 or email

Information about the person making the referral
Date of referral:
Please indicate which service you’d like to refer to:
Please enter your name and contact details:
Referrer’s name
Organisation name
Role/ job title
Contact number
Contact email

Client contact info

Contact information
First name
Last name
Aliases
DOB
Next of kin – who can we contact in an emergency?
Name / Relationship
Contact information
NOK Safe contact notes
Addresses
Current address
Current Local Authority
Does the perpetrator live at this address? / Yes ☐ No ☐ Don’t Know ☐
Client Contact info
Details Safe to contact?
Phone / Yes / No
Email / Yes / No
Safe contact notes
Accessibility requirements
Does this client have any accessibility requirements (for example hearing loop) / Yes ☐
No☐
Don’t Know ☐ / If yes, please provide details:
Does this client require an interpreter? / Yes ☐
No☐
Don’t Know ☐ / If yes, please provide details:

Crèche needs

If the person being referred requires crèche facilities, please provide children’s names and DOBs below:
Will you need crèche facilities? / Yes / No
Name / DOB
Are there any known risks to working with this client?

Client equalities monitoring

How would this client describe their gender? / Female ☐
Male ☐
In another way:______
Is their current gender different to the sex they were assigned at birth? / Yes ☐
No ☐
Don’t know ☐
How would they describe their ethnicity?
White British ☐
White Irish ☐
White Gypsy or Irish Traveller ☐
Any other White background ☐
Asian British ☐
Asian Indian ☐
Asian Pakistani ☐
Asian Bangladeshi ☐
Any other Asian background ☐
Chinese ☐
Arab ☐ / White and Black Caribbean ☐
White and Black African ☐
White and Asian ☐
Any other mixed/ multiple background ☐
Black British ☐
Black African☐
Black Caribbean ☐
Any other Black background ☐
Other (please specify): ______
Don’t Know ☐
Do they consider themselves to have any kind of disability?
(please tick any that apply) / Physical ☐
Learning ☐
Mental Health ☐
Deaf/ hearing impaired ☐
Blind/ visually impaired ☐
Something else:______
Don’t Know ☐
What is their relationship status?
(tick one option) / Civil partnership ☐
Married ☐
Divorced ☐
Separated ☐
Cohabiting but not married/ CP ☐
In a relationship (not cohabiting) ☐
Widowed ☐
Single ☐
Do they have a faith/ religion?
No religion ☐
Bahai ☐
Buddhist ☐
Christian ☐
Hindu ☐
Jewish ☐
Jain ☐ / Muslim ☐
Shinto ☐
Sikh ☐
Zoroastrian ☐
Other: ______
Don’t Know ☐
What is their sexual orientation?
(tick one option) / Heterosexual/ straight ☐
Gay woman/ Lesbian ☐
Gay man ☐
Bisexual ☐
Something else:______
Don’t Know ☐

Thanks for taking the time to complete this referral.

Please complete the attached Risk Assessment)

To submit your completed document, please email to . Before you send the referral, please check that any relevant additional materials eg MARAC (RIC) are attached.

If you have any queries, please contact 01457 856675.

FREEDOM PROGRAMME RISK ASSESSMENT

To be completed for all Referrals

Assessments of risks relating to substance misuse / Not at all / Only Occasionally / Sometimes / Often / Most or all the time
Do you misuse alcohol? /
Do you misuse prescribed drugs? /
Do you misuse non prescribed drugs? /
Do you misuse solvents? /
Do you misuse any other substances? /
Assessments of risks relating to your mental health history
Do you have any mental health issues including anxiety/depression? / Yes / No
If yes please specify:
Do you have support with mental health issues including appointments with GP, Community mental health team, Psychiatrist? / Yes / No
If yes please specify:
Have you ever self-harmed? / Yes / No
If yes please specify:
Have you ever had suicidal thoughts/suicide attempts? / Yes / No
If yes please specify:

Current Medication

Please specify?
Assessments of risks relating to violent or aggressive behaviour
Do you have a history of violent or aggressive behaviour? / Yes / No
If yes please specify
Have you any present violent or aggressive behaviour or thoughts / Yes / No
If yes please specify
Assessments of risks relating to harm to children or young people
Do you have a history of harm to children or young people / Yes / No
If yes please specify
Have you any present thoughts or intentions to harm a child or young person. / Yes / No
If yes please specify
Assessments of risks relating to offending history
Have you committed any offences against people (assault, murder etc) / Yes / No
If yes please specify:
Have you ever committed any sex offences against adults or children / Yes / No
If yes please specify:
Is the perpetrator of the abuse aware that you are using our services? / Yes / No

Please add any additional information below:

QUALITIES OPPORTUNITIES MONITORING FORM

To help us monitor how our service is being used please complete this monitoring form for each referral. Please circle and specify

AGE GROUP
Under 18 /  / 18 to 25 / 
26 to 35 /  / 36 to 45 / 
46 to 55 /  / 56 to 65 / 
Over 65 / 
RELIGION / BELIEF
Buddhist /  / Christian / 
Hindu /  / Jewish / 
Muslim /  / Sikh / 
No Religion /  / Prefer Not To Say / 
Other Religion / 
Other (Please specify): …………………………………………………………
ETHNIC ORIGIN
Asian or Asian British / White
Indian /  / British / 
Pakistani /  / Irish / 
Bangladeshi /  / Other European / 
Any other Asian Background /  / Other Non-European / 
Black or Black British / Dual Heritage
Caribbean /  / White & Black Caribbean / 
African /  / White &Black African / 
Other Black Background /  / White and Asian / 
Other Dual Heritage / 
Other (Please specify): …………………………………………………………
MARITAL STATUS
Single /  / Married / 
Civil Partnership /  / Widowed / 
Divorced /  / Separated / 
Co-habiting / 
SEXUALITY
Heterosexual /  / Lesbian / 
Bi-sexual /  / Homosexual / 
Transgender /  / Prefer Not to Say / 
REGIONAL LOCATION
High Peak /  / Derbyshire Dales / 
EMPLOYMENT STATUS
Receiving ESA /  / Receiving Income Support / 
Receiving JSA /  / Receiving Incapacity / 
Part Time Work /  / Full Time Work / 
Other / 
FAMILY COMPOSITION
No Dependants /  / Dependant(s) Under 5 / 
Dependant(s) 6 – 12 /  / Dependant(s) Over 12 / 
No longer dependant(s) Over 18 / 
DISABILITIES

Do you consider yourself to have a disability? (The Equality Act 2010 considers a person to be disabled if they have a "mental or physical impairment that has a substantial and long-term adverse effect on their ability to carry our normal day activities.")

YESNOPREFER NOT TO SAY

If YES, please state the type of disability which applies to you. People may experience more than one type of disability, in which case you may indicate more than one. If none of the categories apply, please mark ‘other’.

Physical impairment /  / Physical impairment / 
Sensory impairment /  / Sensory impairment / 
Mental Health condition /  / Mental Health condition / 
Long standing illness /  / Long standing illness / 
Learning disability /  / Learning disability / 
Prefer not to say /  / Prefer not to say / 