GREATER MANCHESTER FIRE AND RESCUE SERVICE PERSON AT INCREASED RISK OF FIRE SAFE AND WELL VISIT REFERRAL FORM Service: e.g. Mental PCFT Locality e.g. Health, Specialist or Bury, Oldham, Community Rochdale, Trafford. Date Name of Person Contact Number Making Referral Client Name D.O.B Client Address & Client Phone No Postcode Name And Contact Number Of The Person Who The Visit is To Be Booked With Reason For Referral Please Complete The Following Section In Full Does anyone in the household have any mental or physical health conditions that may increase their risk of having a fire Yes No or impact on their ability to escape in the event of a fire? Does anyone in the household have any alcohol or drug issues that may increase their risk of having a fire or impact Yes No on their ability to escape in the event of a fire? Has a threat of arson or other fire related threat been made? Yes No Has there been a threat to life made or is this a high risk Yes No domestic violence (MARAC) case? If yes to any of the 4 questions above, please give full details: Are there any risks to GMFRS staff visiting the address? Yes No (Example Risks firearms, weapons, violence, aggression, environmental) If yes, please give details: Email Completed Form To: To Arrange A Joint Visit Telephone: 0800 555 815 Opening Hours Monday Friday 9am To 7pm And Of – Quote ‘Person At Increased Risk Fire’ (Out Of Hours Contact 0161 736 5866)
GREATER MANCHESTER FIRE AND RESCUE SERVICE PERSON AT INCREASED RISK OF FIRE SAFE AND WELL VISIT REFERRAL FORM PCFT Locality e.g. Bury, Oldham, Rochdale, Trafford. Service: e.g. Mental Health, Specialist or Community Date Name of Person Making Referral Contact Number Client Name D.O.B Client Address & Postcode Client Phone No Name And Contact Number Of The Person Who The Visit is To Be Booked With Reason For Referral Please Complete The Following Section In Full Does anyone in the household have any mental or physical health conditions that may increase their risk of having a fire or impact on their ability to escape in the event of a fire? Yes No Does anyone in the household have any alcohol or drug issues that may increase their risk of having a fire or impact on their ability to escape in the event of a fire? Yes No Has a threat of arson or other fire related threat been made? Yes No Has there been a threat to life made or is this a high risk domestic violence (MARAC) case? Yes No If yes to any of the 4 questions above, please give full details: Are there any risks to GMFRS staff visiting the address? (Example Risks firearms, weapons, violence, aggression, environmental) Yes No If yes, please give details: Email Completed Form To: To Arrange A Joint Visit Telephone: 0800 555 815 Opening Hours Monday – Friday 9am To 7pm And Quote ‘Person At Increased Risk Of Fire’ (Out Of Hours Contact 0161 736 5866)