PDAP Group Work Referral Form

Please Fill in the form Below

How to complete this referral:

By completing this referral form, you are helping us to make contact with the client as safely and quickly as possible. If you would 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 particular needs and circumstances.

Eligibility criteria for this service:
Please be sure to check that the client meets the following criteria before making the referral:

If you have any questions about our service, eligibility criteria, or how to make a referral, please contact:

Julie: Group Work Co Ordinator on 07710700912 or Chris: Group Work Facilitator on 07719054946

Outreach Offices: 01484 308307

Alternative Form Download

If you do not wish to fill in the form below you can download the form and print it off and send it back to us by post.

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.

Download Group Work Form

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1. Information about the person making the referral

Untitled

Date of referral*

Please indicate which service you’d like to refer to*

Has the client given consent for the referral to be made?*

Please enter your name and contact details

Referrer’s name*

Role/ job title

Contact number

Contact email*

2. Client contact info

First name*

Last name*

Other names

What do they like to be called?

Oasis/CDP Case Number:

Date of Birth’*

Current address*

Does the perpetrator live at this address?

Phone*

Safe to phone?

Check If Yes

Safe to email?

Check If Yes

Safe contact notes

3. Client Support Needs/Vulnerabilities:

Please tell us more about the support needs the client may have:

Mental Health

Physical Health

Substance Misuse

Offending

Clarify the above / Additional Details:

4. Reason for Referral

Why are you making this referral – how could this client benefit from accessing the programme?

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

This field should be left blank

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