Women’s Aid Leicestershire Ltd
Referral Form
CONFIDENTIAL
Date of Referral : / New Referral: Yes / No / Client Reference Number :
(Office Use Only)
Referrer: / Organisation:
Position: / Telephone No:
Form Completed By: / Position:
Nature of Support Required

IDVA
(Please include a copy of the CAADA DASH Risk Assess) / ISVA / Outreach / Children & Family
Outreach / ADAM
Area: /
Blaby / Charnwood / Hinckley & Bosworth / Melton
Market
Harborough / North West
Leicestershire / Oadby & Wigston
Refuge Referral: / Leicester City / Hinckley / Loughborough / Coalville
Personal Details
Adult Name:
Date of Birth: Age: Gender: / Telephone:
Mobile:

Safe to call / text: Yes No
Address:
Post Code:

Safe to send information: Yes No / Alternative Safe Address:
(Relationship to adult/family):
Telephone Number:
Marital Status: / Sexual Orientation:
Ethnicity : / Religion :
Preferred Language : / Interpreter Required? Yes / No
Health Issues
Any drug, drink, mental health, general health problems or history of self harm:
Any physical or learning disabilities:
NI Number: / Schedule 1 Offender: Yes / No
Tenancy Status: / Owner / Occupier / Private
Rented / Council Tenancy / Housing Assoc. / Temporary
/ Refuge / Homeless
Economic Status: / Immigration Status:
Children’s Details
First Name / Surname / Date of Birth / Age / Gender / Ethnicity
Children’s Address:
(If different from above)
Current C&YPS Involvement : CPP Category of Risk:
Early Help Support: First Response Early Help Locality Hub
Name of Social Worker: Telephone Number:
Any current proceedings with children including:
CYPS Yes / No Civil Yes / No Other :
Client Pregnant? Yes / No E.D.D: Lone parent:
Any other people/family members living in household:
Children’s Issues:
Regarding the Domestic Abuse what have the children heard/seen or experienced:
Witnessed: Physical Verbal Emotional Sexual Financial

Actual: Physical Verbal Emotional Sexual Financial
Has the child/renever suffered any injuries? Yes / No
Were you able to access medical attention for the injuries? Yes / No
Were you assaulted when you were pregnant? Yes / No
Perpetrator Information
Name:
Date of Birth: Age: / Address:
Postcode:
Ethnicity: / Immigration Status:
Relationship of Perpetrator: / Economic Status:
Health Issues/Disabilities/Drug-Alcohol Issues:
Schedule 1 Offender: Previous Offences:
Court Bail information and court appearances:
Civil Orders:
Contact with children:
Case Information and History
Date of last incident: / Was this reported to police: Yes* / No / *Incident No:
Background Information:
(Please tell us about the reason for referral, abuse experienced, support required etc.)
CAADA DASH Risk Assessment Undertaken: Yes / No
Completed By: / Risk Level: / Date:
Referrals are accepted with consent unless safeguarding risk overrides consent; please ensure you are compliant with your agency’s sharing without consent procedures. Please sign below to confirm consent has been obtained or the decision to share information without consent has been made:
Referrer: Signature: Date:
Office Use Only
Risk Assessment Completed By: / Date:
Risk Level: / IDVA Referral Date (if applicable):
Accepted: Yes / No / Letter sent to referrer to confirm
receipt / On Waiting list sent date: / Sure Start Informed(if applicable):
Reason If Not Accepted:
Support Start Date: / Support End Date: / End of Support Notification Sent:

Continuation Sheet - Referral Form

Details of Referrer
Contact: / Agency: / Self Referral:
Form Completed By:
Client Details
Adult’s Name:
Additional Information:

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