Is the perpetrator known to the client? Does the perpetrator live at Yes No Don’t know this address? Phone number Safe to contact? Email address Safe to contact? Safe time to contact client? Domestic violence & risk: Has the client disclosed Yes No domestic violence/abuse? Has a SafeLives Dash risk Yes No If yes, what risk level?: assessment been completed? Risk nominal: Standard or Standard High High If high has a referral been Yes No If yes, when?: made to MARAC? Accessibility requirements: Does this client have any Yes No If yes, please provide details: accessibility requirements (for example, hearing loop, Don’t know braille documents) Yes No If yes, please provide details: Does this client require an interpreter? Don’t know Support needs & additional details: Please tell us about any support needs the client may have: Mental health Substance misuse Physical health Offending Additional details: Please include details of any other professionals involved
Is the perpetrator known to the client? Does the perpetrator live at this address? Yes No Don’t know Phone number Safe to contact? Email address Safe to contact? Safe time to contact client? Domestic violence & risk: Has the client disclosed domestic violence/abuse? Yes No Has a SafeLives Dash risk assessment been completed? Yes No If yes, what risk level?: Risk nominal: Standard or High Standard High If high has a referral been made to MARAC? Yes No If yes, when?: Accessibility requirements: Does this client have any accessibility requirements (for example, hearing loop, braille documents) Yes No Don’t know If yes, please provide details: Does this client require an interpreter? Yes No Don’t know If yes, please provide details: Support needs & additional details: Please tell us about any support needs the client may have: Mental health Physical health Substance misuse Offending Additional details: Please include details of any other professionals involved
victim_support_referral_form.docx