Paladin Referral Form

PALADIN REFERRAL FORM

Paladin referrals should be sent by secure email or other secure method to . If you are sending from a secure email account (.pnn; .gsi; .gov;) please email

Referring agency / Click here to enter text.
Contact name(s) / Click here to enter text.
Telephone / Email / Click here to enter text.
Date / Click here to enter a date.
Victim name / Click here to enter text. / Victim DOB / Click here to enter a date.
Address / Click here to enter text. / Diversity Data (if known)
Choose an item.
Religion or Belief (if known)
Choose an item.
Gender: ☐Male ☐Female
Disability: ☐ Yes / ☐ No
Sexuality: ☐ Heterosexual / ☐ LGBT
Telephone number / Click here to enter text. / Is this number safe to call? / ☐ Yes / ☐ No
Is it safe to leave messages? / ☐ Yes / ☐ No
Client’s Email Address / Click here to enter text. / Is this email safe for us to use? / ☐ Yes / ☐ No
Please insert any relevant contact information e.g. times to call / Click here to enter text.
Perpetrator(s) name (if known) / Click here to enter text. / Perpetrator(s) DOB / Click here to enter a date.
Perpetrator(s) address / Click here to enter text. / Relationship to victim / Click here to enter text.
Children
(please add extra rows if necessary) / DOB / Relationship to victim / Relationship to perpetrator / Address / School
(If known)
Click here to enter text. / Click here to enter a date. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter a date. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text.

PLEASE COMPLETE NEXT PAGE BEFORE SUBMITTING

Reason for Referral / Additional Information

Reason for Referral (Please give a brief background):
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Has the perpetrator been arrested?
If so – what were they charged with? Police bail conditions? / ☐ Yes / ☐ No
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Has the perpetrator attend(ed) court?
(Include details of charge, bail conditions, next court hearing date) / ☐ Yes / ☐ No / ☐Not Applicable
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Is there a local Domestic Violence service involved? / ☐ Yes / ☐ No / ☐Not Applicable / If yes, what are their contact details?
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Has DASH been used? If yes, this will need to be submitted / ☐ Yes / ☐ No / ☐Not Applicable
Has S-DASH 11 stalking questions been used? If yes, this will need to be submitted. Available here. / ☐ Yes / ☐ No
Has the National Stalking Helpline been contacted? / ☐ Yes / ☐ No
Is the victim aware of the referral to Paladin? / ☐ Yes ☐ No / If no, why not?
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Has consent been given? / ☐ Yes ☐ No
Who is the victim afraid of? (to include all potential threats, and not just primary perpetrator) / Click here to enter text.

Paladin National Stalking Advocacy Service, 16-20 Bush House, Bush Fair, Harlow Essex CM18 6NS

Company Number 8361675

PTO