Bradford & District Domestic Abuse Community Support ServicesDate of referral: Member of staff: Ref No:

Has the service user given consent for this referral to be made? YES

1 - REFERRAL DETAILS

Referral Agency: Contact Tel. No: Staff Name:Has referrer contacted any other agency about this client YES NO If so, who and when:

2 - CLIENT DETAILS

Client name: DOB :

Home Address: Post code:Contact Tel. No: Is there a safe time to call? Anytime

Ethnicity: Immigration Status:Languages spoken/proficiency in English:

CHILDREN’S DETAILS

Name DOB/AGE Gender

3 - PERPETRATOR’S DETAILS

Name: Aliases: D.O.B:

Address: Post code:

Relationship to client:

Is there more than one perpetrator? YES No If Yes give details:

4 OTHER INFORMATION

Are there any known health & safety risks from the client toward other service users or staff? If so, what:

Abuse history & current situation where applicable also include legal or police action taken e.g. copy of occurrence log

Has a CAADA/DASH Risk Indicator Checklist been completed?:

YES NO SCORE IF KNOWN: RIC ATTACHED

5 – DVS Duty Use Only OUTCOME

Date Method Outcome (e.g. contact made, no response) Sig.

Client requires: DV Accomm. Signposting /referral to other service Please tick below to confirm the client has given verbal consent for making the transfer/referral & this is a true account of her current situation

EXPLAIN TO THE REFERRING AGENCY/CLIENT that for a Service transfer additional information may be needed.Which service was the referral transferred to: DVSK BWA STAYING PUT Other

Reason for transfer/signposting/referral being made to different service/provider:

Date, time, name of organisation & staff member to whom the referral was passed on:

Client requires this service PLEASE NOW COMPLETE A NEEDS & RISK ASSESSMENT (PART B)

INFO FROM PART B: (To be completed by duty prior to filing in service and/or original files)

Which DVS service was required: CI&OS IDVA TSO CRO/CIO/NEN

Date duty process completed:

E&D Completed: Yes N/A Secure ILR

Name of worker completing data base process: