Referrer's details.
*
First Name
Last Name
Phone
(###)
###
####
Email
*
Organisation
*
Is this referral part of a Child Protection Plan?
Is the client involved in Private Court Proceedings?
Alleged Perpetrator's Information
First Name
Last Name
Phone
(###)
###
####
Email
Address.
Date of Birth
MM
DD
YYYY
Gender
*
Male
Female
Transgender Man
Transgender Woman
Non-Binary
Other
Prefer not to say
Prefer to self-describe
Sex
*
Male
Female
Prefer not to say
Unknown
Sexual Orientation
*
Heterosexual
Gay
Lesbian
Bisexual
Other
Prefer not to say
Unknown
Ethnicity
*
White: British, English, Welsh, Northern Irish or Scottish
White: Irish
White: Gypsy or Irish Traveller
White: Other
Mixed/Multiple Ethnic Groups: White & Black Carribean
Mixed/ Multiple Ethnic Groups: White & Black African
Mixed/ Multiple Ethnic Groups: White and Asian
Mixed/ Multiple Ethnic Groups: Other
Asian/ Asian British: Indian
Asian/ Asian British: Pakistani
Asian/ Asian British: Bangladeshi
Asian/ Asian British: Chinese
Asian/ Asian British: Other
Black/ African/ Caribbean/ Black British: African
Black/ African/ Caribbean/ Black British: Caribbean
Black/ African/ Caribbean/ Black British: Other
Other Ethnic Group: Arab
Other
Prefer not to say
Unknown
Nationality
*
UK
Non-UK
Prefer not to say
Unknown
Marital Status
*
Married/Civil Partnership
Co-Habiting
Single
Separated
Divorced/Legally Dissolved Partnership
Widowed
Prefer not to say
Unknown
Religion
*
Buddhist
Christian
Hindu
Jewish
Muslim
Sikh
No Religion
Other
Prefer not to say
Unknown
Does the client (AP) have any long-standing illness, disability, or infirmity?
Does the AP require any additional accessibility support? E.g., disability access to building, communication difficulties, primary spoken language other than English?
Does the AP require referrals for any additional needs (for example, services for homelessness, parenting issues, drug misuse, social and community support, finance and benefit):
If the AP has children, please provide the children’s details (Please give names, ages, DoB of each child and if they are sons or daughters and include any children not currently living with client).
Please list any depression, anxiety, self-harm or other mental health issues that the AP is experiencing.
Does the AP have any convictions/cautions/warnings against them?
If yes, please provide details.
Has the AP ever had problems with being violent or aggressive towards others?
If yes, please provide details.
Has domestic abuse been reported to the police, at the time of this referral?
*
Yes
No
Unknown
Please state what you hope therapy will achieve for the AP.
Please give any recommendations for the work.
If a risk assessment has already been complete, please summarise the findings.
Victim/Survivor's Information.
First Name
Last Name
Is it safe to contact the victim by:
*
Phone
(###)
###
####
Email
Address
Date of Birth
MM
DD
YYYY
Gender
*
Male
Female
Transgender Man
Transgender Woman
Non-Binary
Other
Prefer not to say
Prefer to self-describe
Sex
*
Male
Female
Prefer not to say
Unknown
Sexual Orientation
*
Heterosexual
Gay
Lesbian
Bisexual
Other
Prefer not to say
Unknown
Ethnicity
*
White: British, English, Welsh, Northern Irish or Scottish
White: Irish
White: Gypsy or Irish Traveller
White: Other
Mixed/Multiple Ethnic Groups: White & Black Carribean
Mixed/ Multiple Ethnic Groups: White & Black African
Mixed/ Multiple Ethnic Groups: White and Asian
Mixed/ Multiple Ethnic Groups: Other
Asian/ Asian British: Indian
Asian/ Asian British: Pakistani
Asian/ Asian British: Bangladeshi
Asian/ Asian British: Chinese
Asian/ Asian British: Other
Black/ African/ Caribbean/ Black British: African
Black/ African/ Caribbean/ Black British: Caribbean
Black/ African/ Caribbean/ Black British: Other
Other Ethnic Group: Arab
Other
Prefer not to say
Unknown
Nationality
*
UK
Non-UK
Prefer not to say
Unknown
Marital Status
*
Married/Civil Partnership
Co-Habiting
Single
Separated
Divorced/Legally Dissolved Partnership
Widowed
Prefer not to say
Unknown
Religion
*
Buddhist
Christian
Hindu
Jewish
Muslim
Sikh
No Religion
Other
Prefer not to say
Unknown
Does the victim/survivor have any long-standing illness, disability, or infirmity?
Does the victim/survivor require any additional accessibility support? E.g., disability access to building, communication difficulties, primary spoken language other than English?
If the victim/survivor has children, please provide the children’s details (Please give names, ages, DoB of each child and thier gender.
Please list any depression, anxiety, self-harm or other mental health issues that the victim/survivor is experiencing.
Does the victim/survivor have any convictions/cautions/warnings against them?
If yes, please provide details.
Is the victim/survivor required to attend any other services or courses?
Please state what you hope therapy will achieve for the victim/survivor.
Please give any recommendations for the work.
If a risk assessment has already been complete, please summarise the findings.
Please confirm that the information provided is correct and that you have obtained the client's permission for this referral.