Updated Oct 2016

FAMILY REFERRAL FORM

Hartlepool
T:03000 20 25 25
E:
Secure email:
/ Durham
T:03000 20 25 25
E:
Secure email:
/ North Tyneside
T:0191 251 3305
E:
Secure email:

Stockton
T: 03000 20 25 25
E:
Secure email: / Middlesbrough
T : 03000 20 25 25
E :
Secure email:
/ Head Office
T : 03000 20 25 25
E:

This form should be completed in conjunction with Harbour’s Referral Guidelines.

1. THE REFERRER

Time & Date / Address of Agency (inc postcode)
Telephone Number / Job Title of Referrer
Name of Referrer / Email Address of Referrer
Agency / Is the person/family aware you are making a referral? / Y N
How did you find out about Harbour? / Saw Literature Recommendation Other, Give details:
Service Areas
Please tick all that might apply for this family/individual / Refuges
Hartlepool Middlesbrough Stockton
North Tyneside Peterlee Durham City
Community Services
Children/Young People’s service Adult Outreach Counselling
Group Work
Perpetrator Interventions Empowerment programmes

2. FAMILY DETAILS

PERSON EXPERIENCING DOMESTIC ABUSE

Name of person experiencing domestic abuse / Date of Birth / M F Trans
Other Known Names / Telephone Number
Email Address:
Ethnic Origin
(please tick) / White-
White British / Black or Black British-Caribbean / Asian or Asian British- Pakistani / Asian or Asian British- Other / Mixed-White and Black Caribbean / Other Ethnic Group-
Other
White-
White Irish / Black or Black British-African / Asian or Asian British- Bangladeshi / Mixed-
White and Asian / Other Mixed Background / Prefer not to say
White-
White Other / Black or Black British- Other / Asian or Asian British- Indian / Mixed-
White and Black African / Other Ethnic Group-
Chinese
Religion / Disability? If yes, give details / Y N Details :
Sexuality / Heterosexual Lesbian/Gay Bi Sexual Other Undisclosed
Address / Postcode
Is the current address:
(Please tick) / Registered Social Landlord, please state : / Private Landlord / Owner / Occupier / Friends/ Family / Other
Please specify
Is the address, email address and telephone number above safe to use? If no, please give alternative contact details. / Y N / Alternative Details :
Person to contact in case of emergency
(inc address, postcode and telephone numbers)
Has a referral been made to another agency?
If yes, please give details. / Y N / Details :
Is an interpreter needed? If yes, please give details. / Y N / Details :
Is the person who is experiencing domestic abuse currently pregnant? / Y N / Details :

PERPETRATOR DETAILS

Name of Perpetrator / Date of Birth
Other Known Names / Telephone Number
Ethnic Origin
Is the perpetrator living at the same property?
If no, what is their address? / Y N / Details :
Is the perpetrator currently pregnant? / Y N / Details :
What level of contact does the perpetrator have with the family?
Details of current risks from the Perpetrator
What is the relationship between the perpetrator and the person experiencing domestic abuse?
Is the perpetrator attending a perpetrator programme? If yes, give details. / Y N / Details :
Are there any Private Law proceedings ongoing? / Y N / Details :
Is there an ongoing criminal case? / Y N / Details :
Is the perpetrator currently on bail? / Y N / Details :
Does the perpetrator have any previous convictions for domestic abuse? / Y N / Details :

CHILDREN AND YOUNG PEOPLE’S DETAILS

Detail any children/young people within the family.

Child/Young Person 1

Name of child/young person / Date of Birth / Sex: M F
Other Known Names / Tel. Number of parent/carer
Relationship to person experiencing domestic abuse / Relationship to perpetrator
Ethnic Origin / Does the child/young person have any special needs or disabilities? If yes, give details / Y N / Details :
Does the child/young person live at the same address as the person experiencing domestic abuse?If no, give details / Y N / Details :
Name of School/Nursery
Is this child / young person demonstrating any violent or abusive behaviour?
If yes, give details / Y N / Details :
Is the young person pregnant? / Y N / Details:
Are there Child Protection or Child in Need issues? If yes, give details. / Y N / Details:
Category of CP:
Are there any other Agencies involved? If yes, give details / Y N / Details:
Does the child have a Social Worker?
If yes, give details including Social Worker’s name and contact information / Y N / Details:
Has an Early Help Assessment been completed on the child/young person?
If yes, give details
Lead Agency / Date of assessment
Copy Supplied / Other Information

Child/Young Person 2

Name of child/young person / Date of Birth / Sex: M F
Other Known Names / Tel. Number of parent/carer
Relationship to person experiencing domestic abuse / Relationship to perpetrator
Ethnic Origin / Does the child/young person have any special needs or disabilities? If yes, give details / Y N / Details :
Does the child/young person live at the same address as the person experiencing domestic abuse? If no, give details / Y N / Details :
Name of School/Nursery
Is this child / young person demonstrating any violent or abusive behaviour?
If yes, give details / Y N / Details :
Is the young person pregnant? / Y N / Details:
Are there Child Protection or Child in Need issues? If yes, give details. / Y N / Details:
Category of CP:
Are there any other Agencies involved? If yes, give details / Y N / Details:
Does the child have a Social Worker?
If yes, give details including Social Worker’s name and contact information / Y N / Details:
Has an Early Help Assessment been completed on the child/young person?
If yes, give details
Lead Agency / Date of assessment
Copy Supplied / Other Information

Child/Young Person 3

Name of child/young person / Date of Birth / Sex: M F
Other Known Names / Tel. Number of parent/carer
Relationship to person experiencing domestic abuse / Relationship to perpetrator
Ethnic Origin / Does the child/young person have any special needs or disabilities? If yes, give details / Y N / Details :
Does the child/young person live at the same address as the person experiencing domestic abuse? If no, give details / Y N / Details :
Name of School/Nursery
Is this child / young person demonstrating any violent or abusive behaviour?
If yes, give details / Y N / Details :
Is the young person pregnant? / Y N / Details:
Are there Child Protection or Child in Need issues? If yes, give details. / Y N / Details:
Category of CP:
Are there any other Agencies involved? If yes, give details / Y N / Details:
Does the child have a Social Worker?
If yes, give details including Social Worker’s name and contact information / Y N / Details:
Has an Early Help Assessment been completed on the child/young person?
If yes, give details
Lead Agency / Date of assessment
Copy Supplied / Other Information

Child/Young Person 4

Name of child/young person / Date of Birth / Sex: M F
Other Known Names / Tel. Number of parent/carer
Relationship to person experiencing domestic abuse / Relationship to perpetrator
Ethnic Origin / Does the child/young person have any special needs or disabilities? If yes, give details / Y N / Details :
Does the child/young person live at the same address as the person experiencing domestic abuse? If no, give details / Y N / Details :
Name of School/Nursery
Is this child / young person demonstrating any violent or abusive behaviour?
If yes, give details / Y N / Details :
Is the young person pregnant? / Y N / Details:
Are there Child Protection or Child in Need issues? If yes, give details. / Y N / Details:
Category of CP:
Are there any other Agencies involved? If yes, give details / Y N / Details:
Does the child have a Social Worker?
If yes, give details including Social Worker’s name and contact information / Y N / Details:
Has an Early Help Assessment been completed on the child/young person?
If yes, give details
Lead Agency / Date of assessment
Copy Supplied / Other Information
Please continue on a separate sheet if there are more than 4 children within the family

OTHER SIGNIFICANT FAMILY MEMBERS

Detail any other significant family members, especially if they are living within the same household and/or they may be vulnerable

Name (inc surname) / Date of Birth / Same Address? / Sex / Telephone number / Relationship to family / Special Needs? / Ethnicity
Y N / M F
Y N / M F
Y N / M F
Y N / M F
Y N / M F
Y N / M F
Y N / M F
Y N / M F

3. BACKGROUND INFORMATION

Give brief details of latest incident of domestic abuse
Was there any Police Involvement? / Y N / Details :
Is any member of the family on MARAC?
If yes, give details. / Y N
Unknown / Name(s) of person(s) on MARAC / Details :
Is any member of the family involved in any legal proceedings relevant to this referral?
If yes, give details including names of any agencies involved / Y N / Name(s) of person(s) involved in legal proceedings / Details :

4. PREVIOUS INVOLVEMENT WITH HARBOUR

Do any members of the family detailed above have any previous involvement with Harbour?
If yes, give details. / Y N / Details :

5. REFUGESERVICE ONLY

Complete only if refuge accommodation is required

Does the woman have recourse to public funds? If yes, give details / Y N Unknown / Details :
If not, can they fund the rent payment or will another agency fund their stay in the refuge? Please give details / Y N Unknown / Details :
Has the woman been in any refuge before? If yes, give details / Y N / Details :
Has the woman ever been evicted from a refuge or other project? If yes, give details / Y N / Details :
Do you have any reason to believe that the perpetrator is likely to pursue the woman to the refuge? If yes, give details / Y N / Details :
Is the woman taking any medication (prescribed or non-prescribed drugs) at the moment?
If yes, give details / Y N / Details:

6. COUNSELLING SERVICE ONLY

Complete only if it is known that counselling is required

Name of person seeking counselling
Has the person received counselling before? If yes, give details / Y N / Details :

7. KEY AGENCIES WORKING WITH THE FAMILY

Name of the person working with this service / Name of agency staff / Name of agency / Telephone Number
GP
Police
Social Services
Probation
Addictive Behaviours
Mental Health
Other
Other
Other
Please continue on a separate sheet if necessary

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Updated Oct 2016

Does any member of the family have any unspent criminal convictions? If yes, give details. / Y N / Name(s) of family member / Details:
Is there a history of self harm by any family member? If yes, give details. / Y N / Name(s) of family member / Details:
Are there any other secondary issues?
(e.g. mental health, dependencies, disabilities, special needs) If yes, give details. / Y N / Name(s) of family member / Details:
Does the referrer consider that any member of the family is currently at risk of harm? If yes, give details / Y N / Name(s) of family member / Details:
Have there been any MAPPA meetings involving any member of this family? If yes, give details / Y N / Name(s) of family member / Details:

8. FURTHER INFORMATION

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Updated Oct 2016

Reason for Referral and other relevant background (including any cultural/faith/language needs)

9. CONFIRMATION

I CONFIRM THAT THE REFERRAL GUIDELINES HAVE BEEN READ AND UNDERSTOODAND THAT THE DETAILS GIVEN ARE ACCURATE. I UNDERSTAND THAT ANY FALSE INFORMATION OR OMISSIONS MAY RESULT IN ANY OFFERS OF SERVICE WITHDRAWN.

Signature/name of referrer / Date
Notes:

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