FearFree Professional Child Referral Form

Is the person aware of the referral and given consent?

Support Required

Referrer information

Referrer name and job title

Referrer contact number

Referring organisation

Referrer Email Address

Child or Young Person’s Information

First Name

Last Name

Date of Birth

Address 1

Address 2

Town

Post Code

Home Telephone

Mobile Telephone

Is it safe to leave a message on the mobile telephone

Preferred contact method

Are there any specific safe times to make contact?

Is the victim currently living with the perpetrator

Diversity Information

Gender identity

Ethnicity

Disability

Sexuality

Language (and dialect)

Is a translator required?

Vulnerabilities

Presenting Issue

Secondary Issue

Third Issue

Involvement from Children’s Services

Is there current involvement from children’s services

If so, at what level

Name of Social Worker

Name of School

School Telephone

Support required

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

Parent/carer information

Parent/carer First Name

Parent/carer Last Name

Parent/carer Date of Birth

Parent/carer Address 1

Parent/carer Address 2

Parent/carer Town

Parent/carer Post Code

Is it safe to post information to the above address?

Parent/carer Email Address

Is email a safe method of contact?

Parent/carer Home Telephone

Is it safe to leave a message on the home telephone

Parent/carer Mobile Telephone

Is it safe to leave a message on the mobile telephone

Preferred contact method

Are there any specific safe times to make contact?

Risk assessment

If referring a child for support due to DA within their own relationship, please attach the relevant risk assessment: a YPDASH RIC and if high risk (scoring over 14 on the DASH and victim is aged over 16) please also ensure a MARAC referral has also been completed and sent to both ourselves support@fearfree.org.uk and MARAC@wiltshire.police.uk

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