MARAC REFERRAL SEND TO THE MARAC TEAM AT HertsMARAC@herts.pnn.police.uk Referring Agency: Date referral completed: Agency Contact Agency Tel No: Name(s): Email: Victim name: Victim DOB: Victim address: Diversity Data: THIS BOX MUST BE COMPLETED Y / N B&ME Y / N Disabled Y / N LGBT Victim Tel No: Gender MALE FEMALE Is this number safe to Any relevant Y / N (if no why not?) call? contact info (e.g times to call) Perpetrator(s) Name: Perpetrator(s) DOB: Perpetrator(s) Address: Relationship to Victim: Children DOB Relationship to Relationship to Address School please add extra rows dd.mm.yy Victim Perpetrator if different to if known if necessary son/daughter/none son/daughter/none Victim REASON FOR REFERRAL/ADDITIONAL INFORMATION Visible High Risk No. of ticks on Potential escalation (4 or more (DO NOT PUT A TICK IN THIS BOX , put the number of DASH RA incidents reported to the Police in the ticks on the Safelives DASH risk assessment) Visible past 12 months) Y / N Ensure DASH is high risk means 14 ticks or more. sent with this referral. Professional Judgement MARAC Repeat If referred under this criteria, provide a (further crime identified within twelve months from the date of the last referral) rationale in the box below as to why and what Y / N Y / N the serious concerns are. Rationale:
MARAC REFERRAL SEND TO THE MARAC TEAM AT HertsMARAC@herts.pnn.police.uk Referring Agency: Date referral completed: Agency Contact Name(s): Agency Tel No: Email: Victim name: Victim DOB: Victim address: Diversity Data: B&ME Disabled LGBT THIS BOX MUST BE COMPLETED Y / N Y / N Y / N Victim Tel No: Gender MALE FEMALE Is this number safe to call? Y / N (if no why not?) Any relevant contact info (e.g times to call) Perpetrator(s) Name: Perpetrator(s) DOB: Perpetrator(s) Address: Relationship to Victim: Children please add extra rows if necessary DOB dd.mm.yy Relationship to Victim son/daughter/none Relationship to Perpetrator son/daughter/none Address if different to Victim School if known REASON FOR REFERRAL/ADDITIONAL INFORMATION Visible High Risk (DO NOT PUT A TICK IN THIS BOX , put the number of ticks on the Safelives DASH risk assessment) Visible high risk means 14 ticks or more. Ensure DASH is sent with this referral. No. of ticks on DASH RA Potential escalation (4 or more incidents reported to the Police in the past 12 months) Y / N Professional Judgement If referred under this criteria, provide a rationale in the box below as to why and what the serious concerns are. Y / N MARAC Repeat (further crime identified within twelve months from the date of the last referral) Y / N Rationale: