Is the client living with the perpetrator/s? Is the client currently refuge accommodation? If the client is under 18, has parent/ carer Yes consent been sought for the referral? No, not sought No, not safe to seek Has the client used our service before? Yes No Not sure Is the client currently pregnant? Yes No Not sure If yes, due date: Primary language Other languages spoken How they describe their gender? Female Male In another way:_________________ Is the client’s gender different to the gender Yes No Don’t know they were assigned at birth? (Are they transgender?) Client’s ethnicity White British Asian Bangladeshi Black British White Irish Any other Asian Black African White Gypsy or Irish background Black Caribbean Traveller Any other Black background Any other White White and Black Caribbean background White and Black African Chinese White and Asian Arab Asian British Any other mixed/ multiple Any other ethnic group Asian Indian background Don’t know Asian Pakistani Does the client have a faith/ religion? No religion Hindu Shinto Bahai Jewish Sikh Buddhist Jain Zoroastrian Christian Muslim Any other religion Don’t know What is their nationality? Please specify:________________________________ Don’t know What is their relationship Civil partnership In a relationship (not status? Married cohabiting) (tick one option) Divorced Widowed Separated Single Cohabiting but not married Don’t know How would they describe Heterosexual/ straight Bisexual their sexual orientation? Gay woman/ Lesbian Don’t know
Is the client living with the perpetrator/s? Is the client currently refuge accommodation? If the client is under 18, has parent/ carer consent been sought for the referral? Yes No, not sought No, not safe to seek Has the client used our service before? Yes No Not sure Is the client currently pregnant? Yes No Not sure If yes, due date: Primary language Other languages spoken How they describe their gender? Female Male In another way:_________________ Is the client’s gender different to the gender they were assigned at birth? (Are they transgender?) Yes No Don’t know Client’s ethnicity White British White Irish White Gypsy or Irish Traveller Any other White background Asian British Asian Indian Asian Pakistani Asian Bangladeshi Any other Asian background White and Black Caribbean White and Black African White and Asian Any other mixed/ multiple background Black British Black African Black Caribbean Any other Black background Chinese Arab Any other ethnic group Don’t know Does the client have a faith/ religion? No religion Bahai Buddhist Christian Hindu Jewish Jain Muslim Shinto Sikh Zoroastrian Any other religion Don’t know What is their nationality? Please specify:________________________________ Don’t know What is their relationship status? (tick one option) Civil partnership Married Divorced Separated Cohabiting but not married In a relationship (not cohabiting) Widowed Single Don’t know How would they describe their sexual orientation? Heterosexual/ straight Gay woman/ Lesbian Bisexual Don’t know
SASS%20Referral%20form.docx