Gloucestershire Domestic Abuse Support Service

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

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

Self-referral

Professional referral

Referrer

Details of the person making the referral:

Name

Role

Organisation

Telephone number

Email address

Client

Details of the person being referred:

Name

Date of birth

Address

Telephone number

Email address

Ethnicity

Gender

First language

Special needs

None

Physical disability

Learning difficulty

Mental health issues

Complex needs

Are they open to social care?

Yes

Not sure

Provide details of the circumstances that led to this referral (max 500 words)

Are the client and alleged perpetrator in a relationship?

Yes

Are the client and alleged perpetrator separated but living in the same property?

Yes

Alleged perpetrator

Details of the alleged perpetrator:

Name

Date of birth

Address

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

Risk assessment

Has a risk assessment been completed?

Yes

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

Consent

Has the client consented to this referral?

Yes

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