Bath Freedom Programme

Referral Form

Contact: 01225 354659; 07531116548; Fax 01225407711

Your Agency: / Referrer: / Phone: / Date:
Client Details
Clients Name:
D.O.B / Ethnicity / Preferred Language:
Any disability/mobility issues?
Address:
Telephone Number (SAFE contact numbers)
Is It Safe To Contact Client: Yes/No
Give brief detail of domestic abuse history:
What has prompted this referral?
Perpetrators Name:
Is Client Living With Perpetrator?: Y / N
Children’s Details
Name: / D.O.B: / Name And Relationship Of Person Child Living With? / On ‘At Risk’ /Child in Need? Y / N
Please state if Crèche is required Yes/No, if Yes, please give the age of children
Legal Protection Currently In Place
Are there any court orders currently in place relating to any family members (adults or children): Y / N, If yes please give details:
Substance Misuse
Does client identify as having substance use issues? Y / N, If yes please give details:
Does client identify perpetrator as having substance use issues? Y / N, if yes please give details below:
Agency Involvement
Has there been Police involvement? YES/NO
Are the family under the MARAC (Multi-agency Risk Assessment Conference)? YES/NO
Are there any other agency involvement? YES/NO
If yes, please give details.
Client Consent
Data Protection requirements demand that the client’s permission be given before passing personal information to another agency. If the client cannot sign the form in person to confirm this, you may sign on their behalf. Signing the form on behalf of the client confirms that their permission has been given.
I (client name) ______have checked the information on this form and agree that it is accurate. I consent to this information being shared with the agencies noted above, and recorded in a database.
Client Signature: ______Date: ______
or tick here □ if consent given by phone
Referrers Signature: ______Date: ______

What will happen next?

If safe to do so, we will make contact with the client to discuss the programme and arrange attendance. Unfortunately, we are not able to liaise with the referrer unless there are problems or it is specifically requested.

Official Use only
Date