Office 01900 67167

Helpline 07712117986

Text 07860021756

Email:

Website:

West Cumbria Domestic Violence Support

Unit 2a Dobies Business Park,

Lillyhall,

Workington,

Cumbria

CA14 4HX

Adult Referral Form

Client Name
Current Address(including post code)
Contact Number
Is it safe to contact?
If not please give details
Date of Birth
Gender(male/female)
Occupation
Disability(if any)
Ethnic Origin & Religion
GP Name
GP Address
Is there any involvement with any other agencies e.g Social Services

Office 01900 67167

Helpline 07712117986

Text 07860021756

Email:

Website:

West Cumbria Domestic Violence Support

Unit 2a Dobies Business Park,

Lillyhall,

Workington,

Cumbria

CA14 4HX

Current or Ex Partner Name
Ethnic Origin
Address
Date of Birth
Contact Number
Occupation
Occupation Address and Telephone Number
Child Name / DOB
Address (if different) / Fathers Name & Address
School Attending
Child Name / DOB
Address(if different) / Fathers Name & Address
School Attending
Child Name / DOB
Address (if different) / Fathers Name & Address
School Attending

Office 01900 67167

Helpline 07712117986

Text 07860021756

Email:

Website:

West Cumbria Domestic Violence Support

Unit 2a Dobies Business Park,

Lillyhall,

Workington,

Cumbria

CA14 4HX

Part B Risk Assessment Form

1. Is the applicant verbally, Physically or Sexually Aggressive? / YES / NO
Please state any details
2. Is this behaviour towards others or the environment? / YES / NO
Please state any details
3. Are there any known risks at the applicants address/ what are they if any? / YES / NO
Please state any details
4. Does the applicant self harm/ any eating disorders etc? Have they attempted suicide, if so when – how – why? / YES / NO
Please state any details
5. Has the applicant any previous mental health issues? Do they currently have a mental health worker? / YES / NO
Please state any details
6. Has the applicant got / had any history of drug/alcohol or solvent dependency?(including prescription drugs) / YES / NO
Please state any details
7. Has the applicant had any criminal convictions?(including arrests even if they have not led to conviction) / YES / NO
Please state any details
8. Has the applicant had any previous criminal history of sex or domestic violence offences?(including arrests even if they have not led to conviction) / YES / NO
Please state any details
9. Does the applicant have any contact with any other agencies i.e. Probation, Bail Order, Out on Licence, Social Services? / YES / NO
Please state any details
10. Is the applicant vulnerable to abuse from others or do they represent a threat of abuse to others? / YES / NO
Please state any details
11. How long is it since they perpetrated abuse?(physical, emotional, sexual)
Please state any details
12. Are there any other risks/recent history which have not been identified? / YES / NO
Please state any details

Office 01900 67167

Helpline 07712117986

Text 07860021756

Email:

Website:

West Cumbria Domestic Violence Support

Unit 2a Dobies Business Park,

Lillyhall,

Workington,

Cumbria

CA14 4HX

Name of Referrer
Position and Organisation
Address(including postcode)
Contact Numbers
Email Address
Reason for Referring
Date

Please sign and return by post to:- West Cumbria Domestic Violence Support, Dobies Peugeot Showroom (upper floor), Dobies Business Park, Lillyhall West, Workington, Cumbria, CA14 4HX

Or email to:-

Signature of Client:
Signature of Referrer:
Form completed by:
Date:

Thank you

Office 01900 67167

Helpline 07712117986

Text 07860021756

Email:

Website:

West Cumbria Domestic Violence Support

Unit 2a Dobies Business Park,

Lillyhall,

Workington,

Cumbria

CA14 4HX

Client Agreement

This is an arrangement between WCDVS counsellor and ______. The agreement describes the way in which we will work together.

Reasons for the Agreement;

Aims of the Work;

Confidentiality and Privacy

If you tell us about a child/person being hurt or a law being broken we will have to do something with this information. Before we do so we will try to discuss the situation with you. Apart from these times we will keep our sessions confidential.

All disclosures are to remain confidential unless the above situation arises. This will keep both client and counsellor safe.

Access to Files;

You can ask to see your file at any time.

Complains Procedure;

It is hoped that you are happy with the work undertaken at WCDVS. If you are not WCDVS has a complaints procedure. If you wish to use this procedure, then the first step is to contact the Manager at WCDVS.

Review of the Work;

After we have met together for eight sessions, we will arrange a Review Meeting to look at how the sessions are going and to plan for any other support you need.

Changes to the Agreement;

If you want to change this agreement then it will be discussed and agreement reached as to what needs to happen.

All disclosures are to remain confidential unless the above situation arises. This will keep both client and counsellor safe.

All disclosures by members of the group are to remain confidential and are not to be discussed outside the group unless the above situation applies in which case the group facilitators will inform the relevant people. This will keep the group safe. Should anyone break confidentiality, that person will be asked to leave the group and appropriate action taken.

Signatures;

Name ______Signed ______

Name ______Signed ______

Date ____/____/____