Positive Relationship Gloucester Referral Form

Referrer Information

Referrer name and job title

Referrer contact number

Referring organisation

Referrer Email Address

Where did you hear about our service (self-referral only):

Service User Information

First Name

Last Name

Date of Birth

Address 1

Address 2

Town

Post Code

Home Telephone

Mobile Telephone

Email Address

Gender identity

Ethnicity

Disability

Marital Status

Partner / Ex Partner details

Full Name

Date of Birth

Pregnant: Due Date:

Disability

Marital Status

Home Telephone

Mobile Telephone

Email Address

Gender identity

Ethnicity

Address, including postcode

Child(ren) information

Child 1

Child Full Name

Child Date of Birth

Address (if different from above)

Child Gender identity

Child Disability

Child on CIN

Biological to Service User

Child on Safeguarding Plan

Child 2

Child Full Name

Child Date of Birth

Address (if different from above)

Child Gender identity

Child Disability

Child on CIN

Biological to Service User

Child on Safeguarding Plan

Child 3

Child Full Name

Child Date of Birth

Address (if different from above)

Child Gender identity

Child Disability

Child on CIN

Biological to Service User

Child on Safeguarding Plan

Current Situation

Motivation to change, commitment to the full 25 week programme: Please add as much detail as possible.

Other agencies involved:

Any known risk to workers / professionals?

Risk Assessment

Are there any drug/alcohol/substance misuse issues?

Are there any mental health issues (including risk of suicide and self harm)?

Are there any non molestation / court orders currently in place?

Are there any criminal convictions/offending history?

Are you subject to or named in any protective orders (e.g. non-molestation order)?

Are there any risks of harm to children or young people?

Is English an additional language?

Are there any physical health issues or disabilities?

If yes to any of the above please give details below:

The evaluation questions we are required to ask are:

Has attendance on the PRG DVPP reduced harm to the child/ren
Have the Local Authority Children’s Service reduced their support? ie, Reduced from LAC, Have the children come off a Safeguarding Plan /been reduced to CIN/closed by Children’s Services
Have Referring Agencies received regular updates on participation/risk from Fearfree?
If the referral has come from the Army Welfare Service (AWS)/Unit Welfare Office (UWO) have they seen improvement in the soldier’s behaviour at work since being on/completing the group?

Exclusion Criteria:

We are unable to accept referrals who are currently involved with family court (CAFCASS)
We are unable to accept referrals who have an open DA criminal investigation
We are unable to accept referrals who are in bail conditions
We are unable to accept referrals who live out of the Gloucestershire county

If this person’s situation changes or if the support is no longer needed, please inform us on prggloucester@fearfree.org.uk or 01452 529 866

Positive Relationship Gloucester Referral Form

Domestic Violence Perpetrator Programme (DVPP)

Referrer Information

Service User Information

Partner / Ex Partner details

Child(ren) information

Child 1

Child 2

Child 3

Current Situation

Risk Assessment

The evaluation questions we are required to ask are:

Exclusion Criteria: