FearFree Professional 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

Service User 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

Email Address

Preferred contact method

Are there any specific safe times to make contact?

Is the victim currently living with the perpetrator

Diversity Information

Gender identity

Marital Status

Ethnicity

Religion

Disability

Sexuality

Language (and dialect)

Is a translator required?

Vulnerabilities

Presenting Issue

Secondary Issue

Third Issue

Military involvement

Ex-armed forces

Current military

Partner ex-military

Partner current military

Child(ren) information

Is there current involvement from children’s services

If so, at what level

Name of Social Worker

Is the victim 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 victim

Child 2

Child Full Name

Child Date of Birth

Address (if different from above)

Child Gender identity

Child Disability

Child Ethnicity

Relationship to victim

Child 3

Child Full Name

Child Date of Birth

Address (if different from above)

Child Gender identity

Child Disability

Child Ethnicity

Relationship to victim

Support required

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

Alleged perpetrator details

If completing for victim support, please complete the following:

Perpetrator Full Name

Perpetrator Date of Birth

Perpetrator Address, including postcode

Victim details

If completing a referral for Behaviour Change support, please complete the following:

Victim Full Name

Victim Date of Birth

Victim Address, including postcode

Has the victim consented to contact from FearFree

Risk assessment (DASH)

Please attach the relevant risk assessment: a DASH for a victim or a RIC for a perpetrator. If high risk, please also ensure a MARAC referral has also been completed and sent to both ourselves spa@fearfree.org.uk and MARAC@wiltshire.gov.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