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Referral form

Please provide as much information as possible. If you have any questions, contact us on 01452 726570 or email support@gdass.org.uk.

Referral type

Referrer

Details of the person making the referral:

Client

Details of the person being referred:

Gender
Special needs
Are they open to social care?
Are the client and alleged perpetrator in a relationship?
Are the client and alleged perpetrator separated but living in the same property?

Alleged perpetrator

Details of the alleged perpetrator:

Children

Details about the client's first child:

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

Details about the client's second child:

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

Details about the client's third child:

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

Details about the client's fourth child:

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

Details about the client's fifth child:

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

Details about the client's sixth child:

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

Risk assessment

Has a risk assessment been completed?

If yes, please send the assessment to gdass.referral@gsg.cjsm.net.

Consent

Has the client consented to this referral?