Positive Relationships Gloucestershire Referral Form

Support Required

Please provide additional information and reason for referral/current situation:

Service User Information

First Name

Last Name

Date of Birth

Address 1

Address 2

Town

Post Code

Is it safe to post information to the above address?

Home Telephone

Is it safe to leave a message on this phone?

Mobile Telephone

Is it safe to leave a message on this phone?

Email Address

Is email a safe method of contact?

Preferred contact method

Are there any specific safe times to make contact?

Diversity Information

Gender identity

Marital Status

Ethnicity

Religion

Disability

Sexuality

Language (and dialect)

Is a translator required?

Vulnerabilities

Mental health

Substance/alcohol misuse

Learning difficulties

Physical health issues or disability

Self-harm or suicidal attempts (please provide additional information)

Criminal convictions

Are you subject to any protective orders (non-molestations)

Military involvement

Ex-armed forces

Current military

Partner ex-military

Partner current military

Current Partner or Ex-Partner Details

Domestic abuse support only (Must provide partner details to be eligible for support)

Full Name

Address, including postcode

Relationship Type

Date of Birth

Telephone Number

Is your current or ex-partner aware of where you are living?

Are you living with current/ex-partner

Child(ren) information

Is there current involvement from children’s services

If so, at what level

Name of Social Worker

Is there previous, current, or are you planning, involvement from CAFCASS/private family court?

Details if yes:

Are you or your (ex)partner currently pregnant

Child 1

Child Full Name

Child Date of Birth

Address (if different from above)

Child Gender identity

Child Disability

Child Ethnicity

Relationship to you

Child 2

Child Full Name

Child Date of Birth

Address (if different from above)

Child Gender identity

Child Disability

Child Ethnicity

Relationship to you

Child 3

Child Full Name

Child Date of Birth

Address (if different from above)

Child Gender identity

Child Disability

Child Ethnicity

Relationship to you

Police involvement (if applicable/known)

Date reported:

Police contact details:

Brief outline of incident:

If this person’s situation changes or if the support is no longer needed, please inform us on spa@fearfree.org.uk or 01225 775 276