Who has custody of this child/young person? Does the perpetrator No contact with perpetrator have any contact with No formal contact arrangements in place the child/young person? Perpetrator has sole custody Perpetrator has supervised contact Survivor has sole custody Perpetrator has unsupervised contact equalities monitoring How would this child/teen Female describe their gender? Male Other (please specify): Don’t Know Is their current gender different Yes to the sex they were assigned No at birth? Don’t Know The 2010 Equality Act defines disability as physical or mental impairment has ‘a a substantial and long term adverse [negative] effect on their ability to carry out normal day to day activities’ Based on the definition Physical Deaf/ hearing impaired above, do they consider Learning Blind/ visually impaired themselves to have any kind Mental Health Other (please specify): of disability? Don’t Know (please tick any that apply) How would they describe their ethnicity? White British White and Black Caribbean Irish White and Black African White Gypsy or Irish Traveller White and Asian Any other White background Any other mixed/ multiple background Asian British Black British Asian Indian Black African Asian Pakistani Black Caribbean Asian Bangladeshi Any other Black background Any other Asian background Other (please specify): Chinese Don’t Know Arab Do they have a faith/ religion? No religion Muslim Bahai Shinto Buddhist Sikh Christian Zoroastrian Hindu Other (please specify): Jewish Jain Don’t Know
Who has custody of this child/young person? Does the perpetrator have any contact with the child/young person? No contact with perpetrator No formal contact arrangements in place Perpetrator has sole custody Perpetrator has supervised contact Survivor has sole custody Perpetrator has unsupervised contact equalities monitoring How would this child/teen describe their gender? Female Male Other (please specify): Don’t Know Is their current gender different to the sex they were assigned at birth? Yes No Don’t Know The 2010 Equality Act defines disability as ‘a physical or mental impairment has a substantial and long term adverse [negative] effect on their ability to carry out normal day to day activities’ Based on the definition above, do they consider themselves to have any kind of disability? (please tick any that apply) Physical Learning Mental Health Deaf/ hearing impaired Blind/ visually impaired Other (please specify): Don’t Know How would they describe their ethnicity? White British Irish White Gypsy or Irish Traveller Any other White background Asian British Asian Indian Asian Pakistani Asian Bangladeshi Any other Asian background Chinese Arab 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 Other (please specify): Don’t Know Do they have a faith/ religion? No religion Bahai Buddhist Christian Hindu Jewish Jain Muslim Shinto Sikh Zoroastrian Other (please specify): Don’t Know
CAT-referrl-form.docx