Referrer Name

Referrer Organisation

Referrer Job Title

Referrer Phone Number

Referrer Email Address

Parent/person with parental responsibility has consented to this referral? Parent/person with parental responsibility has consented to this referral?YesNo*

*If no please explain the reason why consent has not been sought or not been granted

Name

Phone Number

Phone Safe to Contact? Phone Safe to Contact?YesNo

Text

Text Safe to Contact? Text Safe to Contact?YesNo

Email Address

Email Safe to Contact? Email Safe to Contact?YesNo

Preferred Method of Contact? Preferred Method of Contact?PhoneTextEmail

Safe Contact Notes

What are the best times to contact?

Is the child/young person being referred aware of this referral? Is the child/young person being referred aware of this referral?YesNo

Client Name

Client Date of Birth

Client Address

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 or additional needs? Do they have a disability or additional needs?Yes*NoUnknown

Please provide any other needs that WMWA should be aware of at this stage.

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

Is the child/young person at school or college? Is the child/young person at school or college? Yes*No

*If yes, please give the name of the school and location eg Worcester, Hereford, Leominster, Malvern etc

Please provide details of any current domestic abuse concerns within the household. This should also include information about the alleged perpetrator and indicate if any current child contact arrangements are in place.

Is the child/young person known to Children’s Social Care and on a formal plan? If so, please provide details including contact information for the key worker for the child / family.

Is the young person involved in an abusive teen relationship? Is the young person involved in an abusive teen relationship?YesNo

Are the Probation Service, MARAC or the Police involved with the family, and are there any Court conditions/requirements in place?

Are the family engaged in the DRIVE programme? Are the family engaged in the DRIVE programme?YesNo

What do you consider to be the main desired outcomes from West Mercia Women’s Aid support for the child/young person? What are the existing strengths for the child/young person that can be built upon?

Are the family involved in any other domestic abuse programme or intervention?