Horizons Domestic Abuse Services Referral Form

Page 1

To make a referral for support please complete the form below with as much detail as possible. If you would like to discuss the referral you can email horizons@ecpbedford.org or call our helpline 0300 131 7154. We aim to respond to referrals within 48 working hours.

Has a MARAC referral been completed for this client in relation to this referral? If yes, please refer to Victim Support High Risk IDVA Service.

https://bedsdv.org.uk/get-help/victim-support-bedfordshire/

Details of person being referred:

Is the person being referred an adult or a child?

Adult

Child

First Name

Last Name

Phone Number

Is the phone number safe to leave a voicemail on?

Yes

No

Is the phone number safe to leave a text message on?

Yes

No

What would be a safe time to call you?

Safe Email Address

Address Line 1

Address Line 2

City

Postal Code

Exact Date of Birth known?

Yes

No

Date of Birth

Estimated Date of Birth

If the exact date of birth is not known, an estimated/tentative date of birth can be entered here.

Sex assigned at birth

Gender

Preferred pronouns

Sexuality

Ethnicity

Describe Needs

Please provide details, including any accessibility requirements such as wheelchair access or communication needs.

Religion

Immigration Status

Languages Spoken

Interpreter required?

Yes

No

Support Delivery Preference

Any other information regarding their support delivery preference

Parent/Carer Contact Details

Full Name of Parent/Carer

Phone Number

Email

Relationship to Child

Page 2 - Alleged Perpetrator details

Are details of the alleged perpetrator known?

Yes, alleged perpetrator details are knownNo, alleged perpetrator details are unknown or unavailable

Alleged perpetrator details

Name

Exact Date of Birth known?

Yes

No

Date of Birth

Estimated Date of Birth

If the exact date of birth is not known, an estimated/tentative date of birth can be entered here.

Ethnicity

Address details (if it's different from before)

Address Line 1

Address Line 2

City

Postal Code

What is the relationship to person being referred?

Page 3 - Children living at same address. Go to next page if none.

Are there any children or dependants who may be affected, or at risk as a result of the circumstances described in this referral?

Yes

No

Children living at same address?

Yes

No

Child Details

Full Name

Relationship to client

Gender

Male

Female

Non-Binary

Date of Birth

Estimated Date of Birth

If the exact date of birth is not known, an estimated/tentative date of birth can be entered here.

Mother

Father

School

Does this child have current contact with the alleged perpetrator?

If yes, please specify.

Page 4 - Referrer's details

First Name

Last Name

Email

Phone Number

Job Title

Agency

Are there any other agencies involved?

Yes

No

If yes, please give us details below

Name of Worker:

Phone Number

Job Title:

Name of Agency:

Email address

Page 7 - Consent and data protection agreement

YMCA Chiltern Group and Early Childhood Partnership take data protection very seriously and are committed to protecting your privacy. Please visit https://oneymca.org/ to view our Privacy Policy. We will process the personal information you provide in a manner which is compliant with all applicable data protection legal requirements. Information provided will not be shared with any third parties without prior consent unless it is necessary for the safeguarding/protection of a child or vulnerable adult.

I agree to the referral and understand why it is being made and my role within it

Yes

I understand that this is a voluntary process/referral and I can withdraw my consent at any time

YesYes, but I want to know more

I understand that information relating to myself or my child’s needs will be recorded and stored on an electronic secure database

YesYes, but I want to know more

I have had the reasons for information sharing and information storage explained to me and I agree to the sharing of information with YMCA Chiltern Group and Early Childhood Partnership

YesYes, but I want to know more

By clicking ‘Yes’ the referrer is confirming that all necessary consent requirements in this referral have been explained to the individual/parent/carer and understood. The referrer is also confirming that the full content of the referral has been explained to the individual/parent/carer concerned.