Trafford Domestic Abuse Services Telephone 0845 241 1117 option1, Fax 0161 872 7149 Return completed form to sender by email Community Services Referral Form Information, Advice and Support (IAS) Service Date of referral Previous service user Y N Name of TDAS Community Worker To be completed by TDAS Referred by Referral contact: Name DOB Age Current address Postcode Contact no. 1 Safe to leave message? Contact no. 2 Safe to write to client? Address fleeing from if different from Recourse to public funds? Y N Current Tenure type Housing Staying with friends/family Trafford Housing Trust Hostel / Refuge NI number: Private let No fixed abode Owner Occupier Other issues: Issues regarding Homelessness Pregnant Physical Disability Substance misuse - Alcohol Sexual orientation - LGBT Learning Disability Mental health issues Substance misuse - Drugs Self harm History of arson History of violence Any schedule 1 conviction?
Gang involvement Anything else? If yes to an issue – please provide details here (e.g. historical substance misuse, a physical disability that requires wheelchair use, current alcohol use, mental health issues that are supported by CMHT, medications etc...) GP Name Name and address of surgery Are there known issues or concerns around verbal or physical aggression from this client? Y N If yes, please detail Ethnicity White British Asian British British Dual Heritage Caribbean Chinese White Pakistani Black African Dual Heritage Asian Not stated Irish Indian Black Caribbean Dual Heritage African Any other White other Asian other Black other Dual Heritage Other Clients first language Clients religion Clients nationality Employed f/t p/t Education f/t p/t Benefits Y N Occupation Name of benefit/s claimed Children in the family If more than 3 children in family please attach their details to referral 1st Childs name DOB & age CP reg CIN School Childs Ethnicity Childs GP Details of any health issues 2nd Childs name DOB & age CP reg CIN School Childs Ethnicity Childs GP Details of any health issues 3rd Childs name DOB & age CP reg CIN School Childs Ethnicity Childs GP Details of any health issues
Details of other people in household Perpetrator name DOB Ethnicity Location What if any, are the main driver/s in the perpetrators abuse Drug misuse Alcohol misuse Mental Health issues Other Does perpetrator know client’s location? Y N Unsure Repeat incidents involving same perpetrator after service engagement? Tick each time incident occurs Type of abuse Physical Relationship Married Emotional Ex Married Psychological Partner Financial Ex-Partner Sexual Son/daughter Other family rel. Are there any injunctions in place? Y N Status of relationship Together Details of injunctions Recent separation Separated (3m +) dates & information Since the last contact with TWA have there been any further incidents? Y N Other agencies involved: i.e. IDVA Name & agency Contact Reason for referral, details of support required: Referred to: (with date of referrals where applicable) Home Fire Risk Safety Trafford Welfare Rights/ Benefit Advice Housing Sexual Assault and Referral Centre Police Counselling Service GP/Health project TDAS Legal Surgery Psychological Wellbeing Service Freedom Programme Victim Support Education TDAS Floating Support Substance Misuse - Drugs Witness Service