ST HELENS MARAC REFERRAL FORM

VICTIM
Full Name
Date of Birth
Address
Contact No
Gender
Ethnicity
Disability
Is person aware of MARAC Referral / YES / NO / Do they give consent / YES / NO
If Consent not given, you must also complete the Information Sharing without Consent ‘Legal Authority to share’ Section below.
Additional Information
e.g. G.P, Occupation, Housing Provider.
PERPETRATOR
Full Name
Date of Birth
Address
Gender
Ethnicity
Additional Information / Known Risks
CHILDREN
Full Name / Gender / DOB / Address
(if different from parents) / School
(if known) / GP Surgery
(if known)
Hidden Male/ Missing Male: See Appendix 10 of MARAC Protocol
Any details known regarding a “Hidden male”
Reasons for referral:
Background /Issues
Attach MERIT Assessment and score below
BRONZE (Low) / SILVER (Medium) / GOLD (High)
Has the case been heard at any other MARAC? If so when? / YES / NO / Date
Who is the client afraid of? (To include all potential threats and not just primary perpetrator)
Where are the client’s greatest priorities to address their safety?
Highlight any relevant information that relates to any of the risk indicators on the MeRIT checklist
Note records of last sightings, meetings or phone calls
Other information (e.g. actions already taken by agency to address clients safety)
Honour related violence (for further information please refer to the MARAC Protocol)
What would most help them to feel safe?
Who does the client feel it is safe to talk to?
Who does the client believe it is not safe to talk to?
Do you believe that there are reasonable grounds for referring this case to MARAC? / YES / NO
Professional Judgement YES / NO (Please explain reasons for “professional judgement”)
Do you believe that there are risks facing the children in the family? Yes/No
If yes, please confirm if you have made a referral to safeguard the children: Yes/No
Do you think that there are risks facing vulnerable adults in the family? Yes/No
If yes please confirm that you liaised with the Adult Social Care Service Yes/No
Practitioners Notes

INFORMATION SHARING – WITHOUT CONSENT

Legal Authority to share without Consent
Protocol relevant OR Legal Grounds (Please tick 1 or more below)
Prevention and detection of crime (Crime and Disorder Act 1998)
Prevention/detection or crime and/or apprehension or prosecution of offenders (DPA, s. 29)
To protect vital interests of the data subject; serious harm or matter of life or death (DPA, Sch. 2 & 3)
For the administration of justice (usually brining perpetrators to justice (DPA, Sch. 2 & 3)
For the exercise of functions conferred on any person by or under any enactment (police/social services) (DPA, Sch. 2 & 3)
In accordance with a court order
Overriding public interest (Common law)
Child protection – disclosure to social services or police for the exercise of functions under the Children Act, where the public interest in safeguarding the child’s welfare overrides the need to keep the information confidential (DPA, Sch. 2 & 3)
Right to life (Human Rights Act, Art. 2 & 3)
Right to be free from torture or inhuman or degrading treatment (Human Rights Act, Art. 2 & 3)
Balance Considerations
Pressing need
Respective risks to those affected
Risk of not disclosing
Interest of other agency/person in receiving it
Public interest in disclosure
Human rights
Duty of confidentiality
Comments
Internal Consultation(Names, dates and advice/decisions)
External consultations: (Home Office guidance, Information-sharing Helpline)
Client Notification
Client notified of disclosure(s)? YES / NO. If NO, Why not? / Date:
Review
Date for review of this situation:
(Review to include feedback from agencies informed as to their response)
______is responsible for ensuring the situation is reviewed on this date
Record following details of information sharing in case file:
Method of contact (e-mail, letter, phone call) / Date information shared
Legal authority for each agency / Agency and named person informed
Review
Date for review of this situation:
(Review to include feedback from agencies informed as to their response)
______is responsible for ensuring the situation is reviewed on this date
Record following details of information sharing in case file:
Method of contact (e-mail, letter, phone call) / Date information shared
Legal authority for each agency / Agency and named person informed
Signed (by Caseworker) / Date
Authorised by Manager / Date
Referring Officer name and Agency
Contact No / Email
Date

Please forward this form,

MERIT assessment and any additional information to:

DV Administrator/ MARAC Co-ordinator.

Tel: 01744 67 7453 / 7454.

Date referral received by MARAC Admin: