Refuge / Safe Accommodation Referral Form

Refuge Referral Form

How to complete this referral:

By completing this referral form, you’re helping us to contact the client as safely and quickly as possible. We’d appreciate it if you could include as much information as possible – this saves the client from being asked the same questions twice and helps us to understand more about their needs and circumstances.

Eligibility criteria for this service:

Please be sure to check that the client meets the following criteria before making the referral:

All Pdap accommodation is for any women aged 16 or above with or without children fleeing domestic abuse.

Accompanying documents:

Please attach the following documents to this referral, if completed:

Recent DASH risk assessment (if one has been done)
Proof of immigration status or recourse to public funds. How to get in touch:If you have any questions about our service, eligibility criteria, or how to make a referral, please contact Pdap’s 24 hr Helpline 0800 052 7222

Alternative Form Download

Please download the form and print it off and send it back to us by post or by email to [email protected]

Simply hit the button below to download the paper version of our form and fill in as much information as possible and send it back to us.

Page 1 of 9

1. Information about the person making the referral

Date of referral*

Please enter your name and contact details

Referrer’s name*

Role/ job title

Agency & Address*

Contact number*

Contact email*

2. Client contact info

First name*

Last name*

Any previous names or preferred name?

Gender:*

Language:*

Sexual orientation:*

Date of Birth’*

N.I Number*

Contact telephone number*

Ethnicity*

Religion*

Relationship status*

Any communication needs *

(e.g. large print, braille, hearing loop)

Any mobility needs *

(e.g., walking stick, wheelchair user)

Does client have connections to Huddersfield?*

3. Emergency Contact person

Name*

Address*

Contact number*

Contact email*

Relationship*

Current Address*

Address fleeing from (if different)

Is property rented/owned?*

Does perpetrator live here?*

Intending to return here?*

Any rent arrears past or present? Social housing? Local authority?*

Date client left address:*

Any other safety notes?*

4. Alleged Perpetrator/s Details (Fleeing Abuse From)

Name/any other names/aliases?*

D.O.B and Gender*

Relationship to Client*

Address*

Occupation*

Does the alleged perpetrator have any links to Huddersfield? *

History of stalking?*

Last incident of stalking?

Does the alleged perpetrator have gang associations or known criminal offences?*

Any other safety notes:

Further Information - More than one perpetrator?

If there is more than one alleged perpetrator, please provide additional details in the box above:

5. Dependants

Are you pregnant? If so, when is you EDD? Please provide midwife details. *

Reply NO if not pregnant

Do you have any children that you wish to be accommodated with you?

Child 1

Name

D.O.B and Age

Gender

Relationship to alleged perpetrator

Nursery or school children currently attend

Child 2

Name

D.O.B and Age

Gender

Relationship to alleged perpetrator

Nursery or school children currently attend

Child 3

Name

D.O.B and Age

Gender

Relationship to alleged perpetrator

Nursery or school children currently attend

Child 4

Name

D.O.B and Age

Gender

Relationship to alleged perpetrator

Nursery or school children currently attend

Are any of your children in your care or not in your care on a Child Protection Plan? (If no, have they been in the past)*

Child Protection Plan More Info

TAF*

Unique Reference Number URN?

S47 (LA Child Protection Enquiry)*

S17 Child in Need*

S31 Care Order*

S20 Voluntary Care arrangement*

Please give details:

Any other relevant child protection issues

Any other relevant child protection issues, such as contact issues, behavioural problems?*

Please give details:

Residency:

Residency: Who do the children live with?*

Please give details:

Physical disabilities?

Do any of your children have special needs or physical disabilities?*

Please give details:

Any risk to children?

Is there known any risk to children from the children? i.e. child on child abuse *

Please give details:

Name of professionals working with children? i.e. social worker/school *

What type of domestic abuse has the client experienced?*

(Discuss: Last incident/ years together/ how long DA has been going on/ types of abuse experienced/ abuse to children)

DASH completed? *

If yes, please provide score and date.

Has the case been heard at DRAMM/ MARAC? *

If yes, please provide details of for the following: Date case last heard (if in the last 12 months): Area case was last heard:

Police involvement/ any civil and/or protection orders in place?*

Been in refuge before? *

If yes, provide dates and reason for moving in & out. Do you give permission to contact the previous refuge? If no, please stated why.

Accessed any other domestic abuse services? *

Please provide details

Are there any known risks to working with this client, including risk from alleged perpetrator/s?*

Please provide details

7. Client’s Support Needs & Vulnerabilities

Mental Health

Any mental health needs?*

Been hospitalised due to mental health?*

Support from professionals around mental health support*

Are you on any medication supporting your mental health needs? *

(please detail what medication and how long you have been prescribed this):

Any history of self-harm?*

If yes how often and when was the most recent incident?

Do you have any history of attempted suicide?*

If yes how often and when was the most recent incident?

Physical Health

Any known learning difficulties?*

Able to live in independently, manage money, cook, self-medicate independently etc?*

Carer supporting with needs?*

Registered with a GP?*

Registered as disabled?*

Are you or your children immuno-compromised?*

Have you or your children been exposed to any infectious diseases? *

If so, please provide details:

Alcohol and substance use

Alcohol use every day or on a regular basis?*

Do you drink heavily on occasion?*

Please detail any relevant information or agencies involved?*

Contact number of agencies of alcohol support:

Registered with a local community substance team?*

Contact number of agencies of substance support *

Recreational or non- prescription drugs usage?*

Please give details:

Risk

Are there known violent or aggressive behaviour to any individual or agency?*

Known arson or damage to properties?*

Probation?*

Due in court or to report to the police station?*

Other Agencies Involved*

Please Include: Name & Job Role, Agency Name, Contact no, Permission to contact (yes/no) for each one.

8. Finance Section

Do you have access to a bank account? *

If so, is this a joint account or a solo account?

Employment

Are you employed? *

Please give details of employer and salary *

Further education, training or volunteering

Further education, training or volunteering? *

Please provide details of education, training*

Benefits

If you are not, what benefits are you receiving?

Name of benefit

Amount £

How often

Is this a solo/ joint claim?

In your account?

Further Benefit information

Debt Management

Do you have any needs around debt management? *

Please give details.*

E.g., rent arrears, credit card, loan & any repayment in place

Support from professionals and contact details:*

9. Immigration Section

For those with no recourse to public funds: The 12 week MVDAC must have been GRANTED and have a National Insurance number in place. Exceptions will be made if Social Care or Housing will agree to pay housing and living costs for the client until Universal Credit has been awarded. This is payable in advance.

Nationality*

What is the client’s immigration status?*

Does the client have access to public funds?*

How will the client be funded in refuge?

Please attach any relevant funding pledges as required.

Upload Funding

Has a MVDAC Concession been applied for? *

Please provide the date it was applied/ granted and any evidence to confirm

Is there any other organisation providing support around the client’s immigration needs?*

Please provide names, roles and contact details

Please tick which documents you can provide to support with your immigration case: *

Passport

Confirmation that DDV Concession has been granted

Residency permit

Children’s documents (if applicable)

This field should be left blank

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Refuge / Safe Accommodation Referral Form

Refuge Referral Form

How to complete this referral:

Eligibility criteria for this service:

Accompanying documents:

Alternative Form Download

Please download the form and print it off and send it back to us by post or by email to [email protected]

1. Information about the person making the referral

2. Client contact info

3. Emergency Contact person

4. Alleged Perpetrator/s Details (Fleeing Abuse From)

5. Dependants

Child 1

Child 2

Child 3

Child 4

Any other relevant child protection issues

Residency:

Physical disabilities?

Any risk to children?

6. Safety and Wellbeing

7. Client’s Support Needs & Vulnerabilities

Mental Health

Physical Health

Alcohol and substance use

Risk

8. Finance Section

Employment

Further education, training or volunteering

Benefits

If you are not, what benefits are you receiving?

Debt Management

9. Immigration Section