Let Go Initial Referral Form Date of intake:

Title / Forename/s / Surname / DOB
Gender √ / M / F / Nat / Ins no / Safe contact number-
Safe times/days
Client’s
Safe address / Client’s
Temp
Address
Housing provider / Sole tenancy?√ / Y / N
Rent / Arrears √ / Y / N / ASB at address√ / Y / N
Registered / Homeless? √ / Y / N / Registered for C B L? √ / Y / N
Ethnicity
Religion / Disability or
Vulnerability
Referring
Referrer’s / Agency
name / Contact
Email / no
Reason for referral/concerns
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Children / Name / Date of Birth
Child 1
Child 2
Child 3
Child 4
Location of children
Child contact with perp / Supervised √ / Y / N / Unsupervised√ / Y / N / Children’s
Services
Involved √ / Y / N
Doesthe
Parental / Perpetrator have
Responsibility / Y / N
Perpetrator forename/s / Surname / DOB
Current Address / Bail address
If different
Charges bought? √ / Y / N / Offence / Bail conditions
Description of perpetrator

During assessment, have you covered the below criteria? √

Completed RIC / Safety/support plan / Copies of docs/id / Access to car
Safe area in the home / Safe place to go / Medical treatment / Personal safety
Spare keys / Contacting police / Changing identity / Protecting privacy

Priority needs Assessment checklist√

Children’s safety & wellbeing / Housing / Finances/benefits / Health & wellbeing
Disability/M Health
Coping strategies
Use of D &/or Alc / Civil/legal options / Criminal case/SDVC support / Counselling and/or therapeutic intervention
Client’s concerns

Potential referrals or signposting

MARAC / Generic F S / DV FS / C Safety team
CAB / Com Law Centre / Shelter / Finances/benefits
Solicitor / ECFSA / Rape Crisis/ISVA / Safety Net
Birchall Trust / Freedom Project / Christians against poverty / Victim Support
Witness Service