DASH RISK ASSESSMENT DOMESTIC ABUSE, STALKING, HARASSMENT & BASED VIOLENCE ‘HONOUR’ High COMPLETING DASH, CIRCLE RISK LEVEL HERE: / Medium / Standard Date: Name of person completing DASH: Agency: The MARAC Referral should be quality assured by a trained practitioner in your agency (this may be your MARAC rep) and / or your manager before submission. Name of your MARAC Rep /champion: Contact number of your MARAC Rep /champion: VICTIM’S DETAILS NAME : DATE OF BIRTH: ADDRESS OF VICTIM: TELEPHONE NO: IS IT SAFE TO CALL? Y / N Is it safe to post to this address Y/N If no please provide an alternative (please tick): (please state): Gender Ethnicity Disability Sexual Orientation (please state - inc. Male / Female / learning disability): (please state): other PERPETRATOR’S DETAILS NAME : DATE OF BIRTH: ADDRESS OF PERPETRATOR: RELATIONSHIP TO VICTIM (please state): Gender (please tick): Ethnicity (please state): Disability Sexual Orientation (please state - inc. Male / Female / learning disability): (please state): CHILDREN’S DETAILS (IF ANY) IF YOU RUN OUT OF ROOM PUT DETAILS IN REASONS FOR REFERRAL DATE OF RELATIONSHIP RELATIONSHIP SCHOOL NAME ADDRESS BIRTH TO VICTIM TO (If known) PERPETRATOR
DASH RISK ASSESSMENT DOMESTIC ABUSE, STALKING, HARASSMENT & ‘HONOUR’ BASED VIOLENCE COMPLETING DASH, CIRCLE RISK LEVEL HERE: High / Medium / Standard Date: Name of person completing DASH: Agency: The MARAC Referral should be quality assured by a trained practitioner in your agency (this may be your MARAC rep) and / or your manager before submission. Name of your MARAC Rep /champion: Contact number of your MARAC Rep /champion: VICTIM’S DETAILS NAME : DATE OF BIRTH: ADDRESS OF VICTIM: Is it safe to post to this address Y/N If no please provide an alternative TELEPHONE NO: IS IT SAFE TO CALL? Y / N Gender (please tick): Male / Female / other Ethnicity (please state): Disability (please state - inc. learning disability): Sexual Orientation (please state): PERPETRATOR’S DETAILS NAME : DATE OF BIRTH: ADDRESS OF PERPETRATOR: RELATIONSHIP TO VICTIM (please state): Gender (please tick): Male / Female / Ethnicity (please state): Disability (please state - inc. learning disability): Sexual Orientation (please state): CHILDREN’S DETAILS (IF ANY) IF YOU RUN OUT OF ROOM PUT DETAILS IN REASONS FOR REFERRAL NAME ADDRESS DATE OF BIRTH RELATIONSHIP TO VICTIM RELATIONSHIP TO PERPETRATOR SCHOOL (If known)
dash_2015_including_marac_referral_form.docx