FAMILY REFERRAL FORM Hartlepool T: 03000 20 25 25 E: Secure email: Durham T: 03000 20 25 25 E: Secure email: North Tyneside T: 0191 251 3305 E: Secure email: Stockton T: 03000 20 25 25 E: Secure email: Middlesbrough T : 03000 20 25 25 E : Secure email: Head Office T : 03000 20 25 25 E: This form should be completed in conjunction with Harbour’s Referral Guidelines. 1. THE REFERRER Time & Date Address of Agency (inc postcode) Telephone Number Job Title of Referrer Name of Referrer Email Address of Referrer Agency Is the person/family aware you are making a referral? Y N How did you find out about Harbour? Saw Literature Recommendation Other, Give details: Service Areas Please tick all that might apply for this family/individual Refuges Hartlepool Middlesbrough Stockton North Tyneside Peterlee Durham City Community Services Children/Young People’s service Adult Outreach Counselling Group Work Perpetrator Interventions Empowerment programmes 2. FAMILY DETAILS PERSON EXPERIENCING DOMESTIC ABUSE Name of person experiencing domestic abuse Date of Birth M F Trans Other Known Names Telephone Number Email Address: Ethnic Origin (please tick) White- White British Black or Black Asian or Asian British- Pakistani Asian or Asian British- Other Mixed-White and Black Caribbean Other Ethnic Group- Other White- White Irish Black or Black British-African Asian or Asian British- Bangladeshi Mixed- White and Asian Other Mixed Background Prefer not to say
White- White Other Black or Black British- Other Asian or Asian British- Indian Mixed- White and Black African Other Ethnic Group- Chinese Religion Disability? If yes, give details Y N Details : Sexuality Heterosexual Lesbian/Gay Bi Sexual Other Undisclosed Address Postcode Is the current address: (Please tick) Registered Social Landlord, please state : Private Landlord Owner / Occupier Friends/ Family Other Please specify Is the address, email address and telephone number above safe to use? If no, please give alternative contact details. Y N Alternative Details : Person to contact in case of emergency (inc address, postcode and telephone numbers) Has a referral been made to another agency? If yes, please give details. Y N Details : Is an interpreter needed? If yes, please give details. Y N Details : Is the person who is experiencing domestic abuse currently pregnant? Y N Details : PERPETRATOR DETAILS Name of Perpetrator Date of Birth Other Known Names Telephone Number Ethnic Origin Is the perpetrator living at the same property? If no, what is their address? Y N Details : Is the perpetrator currently pregnant? Y N Details : What level of contact does the perpetrator have with the family? Details of current risks from the Perpetrator What is the relationship between the perpetrator and the person experiencing domestic abuse? Is the perpetrator attending a perpetrator programme? If yes, give details. Y N Details : Are there any Private Law proceedings ongoing? Y N Details : Is there an ongoing criminal case? Y N Details : Is the perpetrator currently on bail? Y N Details :
Does the perpetrator have any previous convictions for domestic abuse? Y N Details : CHILDREN AND YOUNG PEOPLE’S DETAILS Detail any children/young people within the family. Child / Young Person 1 Name of child/young person Date of Birth Sex: M F Other Known Names Tel. Number of parent/carer Relationship to person experiencing domestic abuse Relationship to perpetrator Ethnic Origin Does the child/young person have any special needs or disabilities? If yes, give details Y N Details : Does the child/young person live at the same address as the person experiencing domestic abuse? If no, give details Y N Details : Name of School/Nursery Is this child / young person demonstrating any violent or abusive behaviour? If yes, give details Y N Details : Is the young person pregnant? Y N Details: Are there Child Protection or Child in Need issues? If yes, give details. Y N Details: Category of CP: Are there any other Agencies involved? If yes, give details Y N Details: Does the child have a Social Worker? If yes, give details including Social Worker’s name and contact information Y N Details: Has an Early Help Assessment been completed on the child/young person? If yes, give details Lead Agency Date of assessment Copy Supplied Other Information Child / Young Person 2
Relationship to person experiencing domestic abuse Relationship to perpetrator Ethnic Origin Does the child/young person have any special needs or disabilities? If yes, give details Y N Details : Does the child/young person live at the same address as the person experiencing domestic abuse? If no, give details Y N Details : Name of School/Nursery Is this child / young person demonstrating any violent or abusive behaviour? If yes, give details Y N Details : Is the young person pregnant? Y N Details: Are there Child Protection or Child in Need issues? If yes, give details. Y N Details: Category of CP: Are there any other Agencies involved? If yes, give details Y N Details: Does the child have a Social Worker? If yes, give details including Social Worker’s name and contact information Y N Details: Has an Early Help Assessment been completed on the child/young person? If yes, give details Lead Agency Date of assessment Copy Supplied Other Information Child/Young Person 4 Name of child/young person Date of Birth Sex: M F Other Known Names Tel. Number of parent/carer Relationship to person experiencing domestic abuse Relationship to perpetrator