Devon and Torbay SARC Referral Form

Devon and Torbay SARC Referral Form

Referrals to besent via email to

For consultation advice prior to referral contact the service within office hours Monday – Friday 9am – 5pm on 01392 436967or 01371 812600

For completion by referrer:
Date of Referral
1. Details of Referrer
Name of person making referral
Agency and Role
Phone Number / Fax Number
Email Address
Address and Postcode
Crime Reference/Log Number
Date of Forensic Medical Examination (if applicable) / Date of police ABE interview (if applicable)
OIC Name and Contact Details
2. Details of Person to be Referred
Name
Date of Birth / Age
Gender
Safe Contact Number
Safe Address and Postcode
GP Name, AddressTelephone Number
Other Professionals involved Names, Addresses & Telephone Numbers
Physical Disabilities / Yes/No Details:
Learning Difficulties / Yes/No Details:
Diagnosed Mental Health Condition / Yes/No Details:
Drugs and/or Alcohol Misuse / Yes/No Details:
Related to CSE or at risk of CSE / Yes/No Details:
3. Details of Adults(for children and young people referrals only)
Name parent / carer 1
Relationship including whether main carer and whether hold parental responsibility
Telephone number
Address and Postcode
Ethnicity / first language
Name of parent / carer 2 or other significant adults
Relationship including whether main carer and whether hold parental responsibility
Telephone number
Address and Postcode
Ethnicity / first language
Are parents/carers aware of this referral? / Has child/young person been made aware of this referral?
Have parents/carers consented to this referral? / Has child/young person consented to this referral?
Health Visitor/School Nurse Name, Address & Telephone Number
Paediatrician (if involved) Name, Address and Telephone Number
4. Children of the household orother relevant children / Child / Young Person 1 / Child Young / Person 2
Name of child
Date of Birth
Gender
Relationship with referred
child / young person
Telephone number
Address and Postcode
Ethnicity / first language
Child / Young Person 3 / Child Young / Person 4
Name of child
Date of Birth
Gender
Relationship with referred child / young person
Telephone number
Address and Postcode
Ethnicity / first language
5. Reason for Referral
Nature of Offence
(Please indicate by marking one or more, as appropriate.) / Rape Assault by Penetration
Sexual Assault Grooming
No disclosure, but concerns of CSA
Other - Details:
When did the Offence Happen
Name of Offender/s
Gender of Offender/s
Relationship to Offender/s
Location of Offence
Offender under the influence of Drink/Drugs at time of offence
Victim under the influence of Drink/Drugs at the time of offence
Relevant information from Police.
(Please give details of the ABE video interview.)
Please provide any further details of the offence/incidents
Any concerning symptoms (including genital bleeding, recurrent vaginal discharge, STI, genital warts, recurrent UTI, sexualised behaviour, other relevant behaviour)
Relevant family and social history
Current or past involvement with Social Care
Relevant information from other professionals e.g. GP/Paediatrician/School Nurse/Health Visitor
6. In addition to this referral to the Oak Centre what other action has been taken in relation to this referral? (MASH, MARAC etc)
9. Any additional information

Consent to Sharing of Personal Information

I have been made aware of the support offered by The Oak Centre, and wish to access this service.

I have been made aware that where a statutory duty exists certain information may be disclosed without my consent.

This agreement complies with the requirement for explicit consent to be given under Schedule 3 of the Data Protection Act 1998

I ………………………………………………………………….(please print name)
give permission for ………………………………………(name of referrer), to make a
referral to Devon SARC on my behalf.
I understand that a nominated ISVA will contact me directly (unless otherwise requested with the client/referrer) to arrange an appointment.
Client signature: …………………………… ……. Date: ……………………………..
Referrer signature: …………………………… ….. Date: ……………………………...

Monitoring Form

Please indicate the answer that applies:

Ethnicity of victim

White British White Other White IrishIndianPakistaniBangladeshiCaribbean African Chinese White and Black Caribbean White and Black African White and Black Asian Other

Religion/Belief

NoneChristianBuddhistHinduJewishMuslim Sikh Other

Sexual Orientation

HeterosexualGayOther

Married/Civil Partnership

YesNo

Pregnant or on Maternity Leave

Yes No

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