Gloucestershire Domestic Abuse Support Service

Call: 01452 726 570 Email: support@gdass.org.uk

Group work referral form

We cannot guarantee a place on the course until GDASS have reviewed all of the referrals to ensure that the group is suitable for all. If your client is not offered a place on the course we will discuss their options around support which may be more suitable to meeting their needs. Please be aware the referral cannot proceed if information on this form is not complete. If you have any questions, contact us on 01452 726570 or email groupwork@gdass.org.uk.

Referral type

Self-referral

Professional referral

Programmes

Six Steps to Domestic Abuse Insight – for men and women who are no longer experiencing domestic abuse.

Breathe – for women currently living with an abusive partner, and those who have left abusive partners.

This referral is for:

Referrer

Details of the person making the referral:

Name

Role, organisation and team

Email address

Telephone number

Client

Details of the person being referred:

Name

Date of birth

Address

Telephone number

Ethnicity

Gender

Alleged perpetrator

Details of the alleged perpetrator:

Name

Date of birth

Address

Description

Car

Children

Details about the client's first child:

Name

Date of birth

Special needs

None

Physical disability

Learning difficulty

Mental health issues

Complex needs

Is the alleged perpetrator the child's parent/carer?

Yes

Add child Remove child

Details about the client's second child:

Name

Date of birth

Special needs

None

Physical disability

Learning difficulty

Mental health issues

Complex needs

Is the alleged perpetrator the child's parent/carer?

Yes

Add child Remove child

Details about the client's third child:

Name

Date of birth

Special needs

None

Physical disability

Learning difficulty

Mental health issues

Complex needs

Is the alleged perpetrator the child's parent/carer?

Yes

Add child Remove child

Details about the client's fourth child:

Name

Date of birth

Special needs

None

Physical disability

Learning difficulty

Mental health issues

Complex needs

Is the alleged perpetrator the child's parent/carer?

Yes

Add child Remove child

Details about the client's fifth child:

Name

Date of birth

Special needs

None

Physical disability

Learning difficulty

Mental health issues

Complex needs

Is the alleged perpetrator the child's parent/carer?

Yes

Add child Remove child

Details about the client's Sixth child:

Name

Date of birth

Special needs

None

Physical disability

Learning difficulty

Mental health issues

Complex needs

Is the alleged perpetrator the child's parent/carer?

Yes

Please detail any social care involvement

History

Details about the history of abuse:

Is the client still in a relationship with the alleged perpetrator?

Yes

Please provide information around the abusive behaviour, please try and include dates where possible

Has the alleged perpetrator used weapons against client and/or others?

Yes

If yes, please provide details

Does the alleged perpetrator have a criminal history/conviction(s) for violence?

Yes

If yes, please provide details

Has there been any threats or violence towards professionals by either the client or alleged perpetrator?

Yes

If yes, please provide details

Risk assessment

Has a risk assessment been completed?

Yes

Note for professionals

Please ensure a DASH has been completed, risk assessed and sent to GDASSgroupwork@greensquareaccord.cjsm.net using CJSM or via Egress to Group.Work@greensquareaccord.co.uk before submitting this referral. We will not accept professional referrals without a DASH.

Consent

Has the client consented to this referral?

Yes

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