Are you looking for refuge Are you looking for refugeFor yourself*For someone else

Where are you seeking refuge from? Where are you seeking refuge from?HerefordshireWorcestershireShropshireTelford & WrekinSomewhere else

Where are you looking for refuge? Where are you looking for refuge?HerefordshireWorcestershireShropshireTelford & WrekinSomewhere else

Referrer Name

Referrer Organisation

Referrer Job Title

Referrer Phone Number

Referrer Email Address

Does the person being referred require immediate safe refuge accommodation? Does the person being referred require immediate safe refuge accommodation?Yes*No

Does the person being referred know about, and consent to, this referral? Does the person being referred know about, and consent to, this referral?YesNo*

*If not, why has this not been sought/given? (If this information is not included, then we cannot accept this referral.)

Client Name

Client Date of Birth

Client Address

Client Phone Number

Phone safe to Contact? Phone safe to Contact?YesNo

Client Email Address

Email safe to contact? Email safe to contact?YesNo

Preferred Method of Contact Preferred Method of ContactPhoneEmailPost

Safe Contact Notes

Gender GenderFemaleMaleNon-binaryInter-sexDeclined to respondUnknownOther*

*If "Other" please give details

Ethnicity EthnicityBritishIrishGypsy or Irish TravellerEastern EuropeanAny Other White BackgroundWhite & Black CaribbeanWhite & Black AfricanWhite & AsianAny other mixedIndianPakistaniBangladeshiChineseAny other Asian backgroundAfricanCaribbeanAny other Black backgroundArabAny other ethnic groupDeclined to answerUnknown

Is English their first language? Is English their first language? YesNo*

*If not please give first language

Do They Have a Disability? Do They Have a Disability?Yes*NoUnknown

*If Yes please tick as appropriate *If Yes please tick as appropriate Physical Learning Mental health disability Hearing impaired Visually impaired

Do They Have Additional Needs Do They Have Additional NeedsYes*NoUnknown

*If Yes please tick as appropriate *If Yes please tick as appropriate Alcohol dependency Drug dependency *Other long term health condition e.g. Type 1 diabetes, epilepsy, chronic allergy

*Please provide any further information relevant to the person’s disability or additional needs that you feel we should know.

Medical Treatment of which WMWA should be aware of at this stage Medical Treatment of which WMWA should be aware of at this stageYes*No

*If yes please give details

Does the person being referred have eligibility to claim benefits in the UK? Does the person being referred have eligibility to claim benefits in the UK?YesNo

Please give us the name and date of birth of each child currently living with the person being referred.

Are local authority children’s services involved with the family? Are local authority children’s services involved with the family?Yes*No

*If yes please explain the nature of that involvement.

Please describe the circumstances for the person being referred that have led you to make the referral. Please explain what you know about the nature of the abuse, and the risks that you believe are posed by the abuse for their physical safety, and/or for their emotional well-being.

Perpetrator Name

Perpetrator Date of Birth

Perpetrator Address

Relationship with person being referred

Is the perpetrator currently living with the person being referred? Is the perpetrator currently living with the person being referred?YesNoSometimes