other MARAC previously? relevant factors which may increase risk eg: arson? If is a risk, has a referral been made to GM Fire Service? Can you explain why you feel this person is at high risk of experiencing further domestic abuse? What are the victim's greatest priorities to address their safety? Consent Has the person’s If are grounds ‘no’, Yes No to share information Yes No consent been obtained without consent? to share information? Immigration Status (eg: asylum seeker, refugee, spousal visa with NRPF, ILR) What type of passport does the young person have eg: British, other (if other, please state which) Nationality Alleged Perpetrator Name: Alias (known as) DOB Ethnicity: Address: Relationships to person: Alcohol or drugs Alcohol Drugs Details:(in treatment or not) involved? If so, name/details of Case Manager Any additional health or care needs? E.g. dementia, learning disability or mental health problems Is the perpetrator currently employed? (If yes, provide details) Has a referral been made to MAPPA (if yes, provide details)
other MARAC previously? relevant factors which may increase risk eg: arson? If is a risk, has a referral been made to GM Fire Service? Can you explain why you feel this person is at high risk of experiencing further domestic abuse? What are the victim's greatest priorities to address their safety? Consent Has the person’s consent been obtained to share information? Yes No If ‘no’, are grounds to share information without consent? Yes No Immigration Status (eg: asylum seeker, refugee, spousal visa with NRPF, ILR) What type of passport does the young person have eg: British, other (if other, please state which) Nationality Alleged Perpetrator Name: Alias (known as) DOB Ethnicity: Address: Relationships to person: Alcohol or drugs involved? Alcohol Drugs Details:(in treatment or not) If so, name/details of Case Manager Any additional health or care needs? E.g. dementia, learning disability or mental health problems Is the perpetrator currently employed? (If yes, provide details) Has a referral been made to MAPPA (if yes, provide details)
Bolton-Young-Persons-MARAC-Referral-Form-Ocotber-2017-V2.docx