DA Advisory Hub Submission Form Step 1 of 4 25% NOTE: ALL INFORMATION RELATING TO THE FAMILY MUST BE ANONYMISED FOR THE PURPOSE OF DISCUSSION WITH EXTERNAL PROFESSIONALS. ANY SUBMISSIONS THAT CONTAIN PERSONAL IDENTIFIABLE INFORMATION WILL BE REJECTED.First Name* Surname* Email* Phone*Role* CSC Team* Team Manager invited and agreed to attend?*YesNoTeam Manager's Name* Team Manager's Email: (Please note that your Team Manager will be invited to the Hub and recommendations emailed to them after)* Child Protection Chair invited and agreed to attend?*YesNoChild Protection Chair's Name* Child Protection Chair's Email* Please indicate which training programmes you have completed (if any):*NoneDomestic Abuse AwarenessFreedom ProgrammeCommunity Groups ProgrammeEscape the TrapCaring DadsIs 1:1 support required?*YesNoI agree by attending the Domestic Abuse Advisory Hub that anything discussed will remain confidential unless we are worried about aspects of the case or that you, or someone close to, is at risk of harm. I also agree that all case information has been anonymised for the purpose of discussion with external professionals:Consent* I agree to the above LCS Number*What plan is the child(ren) currently on?*CPCINHow long have the family been known to CSC?*Less than a year1-2 years3-5 yearsMore than five yearsIs there a Child and Family Assessment in progress?*YesNoHas there ever been a Legal Planning Meeting for this family?*YesNoAre there any current orders in place with regards to the child(ren)?*YesNoWhich orders are in place?*Supervision OrderInterim CareFull Care OrderFull Care Order with PlacementHas this case been heard at MARAC?*YesNoWhen was the case heard at MARAC? MM slash DD slash YYYY Has a Safe Lives DASH RIC been completed?YesNoWhat was the score and outcome?Is there a domestic abuse related criminal history within the past 5 years, or a history of criminality?*YesNoPlease briefly detail convictions*Is the victim still in the relationship with the perpetrator?*YesNoIf no, when did the relationship end? How many children are there?*Please enter a number from 0 to 15.Child(rens) age(s) (click + to add a child's age)* Has the victim been referred to Athena run by Refuge?*YesNoPlease name the Athena caseworker* Does the client have an IDVA from another service? Does the family have recourse to public funds?*YesNoWhat is the immigration status of the victim(s)?*Asylum SeekerRefugee StatusHumanitarian protectionUASC leaveDiscretionary leaveLimited leave to remainIndefinite leave to remainVisaEuropean Union citizenHas the family been discussed at the DA Hub before?*YesNoIf yes, when?* MM slash DD slash YYYY Details of Case*Please include current concerns, support/work already carried out and any behaviours you are concerned about regarding the children. Please anonymise your response and please limit your response to no more than 500 words.Please cover 1. History of Children's Social Care Intervention 2. Recent Interventions 3. Current Situation 4. Social Worker'sConcerns/Perception of Risk What are you hoping to gain from the Advisory Hub?*What is the client's perspective? Please tell us why you are bringing this case to the DA Advisory Hub and what outcomes the client wishes to achieve? Please anonymise your response and please limit your response to no more than 500 words. Please detail the wishes of the non-abusive parent:*Please detail the wishes of the abusive parent:*Select Date*Disclaimer* I agree by attending the Domestic Abuse Advisory Hub that anything discussed will remain confidential unless we are worried about aspects of the case or that you, or someone close to, is at risk of harm OFFICE USE ONLY: DO NOT COMPLETE THIS SECTION UNTIL YOU HAVE BEEN ADVISED TO DO SO AFTER ATTENDING THE HUB. THIS IS RESERVED FOR ONWARD REFERRALS ONCE THE CASE HAS BEEN PRESENTED AT THE HUB.PLEASE SCROLL DOWN TO THE BOTTOM OF THIS PAGE AND CLICK SUBMITParent/Carer DetailsFIRST NAMESURNAMEM/FRELATION TO CHILDDOBETHNICITYRELIGION Child DetailsFIRST NAMESURNAMEM/FRELATION TO CHILDDOBETHNICITYRELIGION Any other significant members of the household or familyFIRST NAMESURNAMERELATIONSHIP TO FAMILY Alleged perpetrators details:FIRST NAMESURNAMERELATIONSHIP TO FAMILY Contact details:ADDRESSPOST CODETEL/MOBILEEMAILSafe to Contact?YesNoSafe to Contact Details:Request for Support: Please select the programme you wish to refer this client to. Please also list any support you would like for yourself (i.e. support from the DA Hub's Specialist Workers). Freedom Programme Children Overcoming Domestic Abuse Caring Dads Specialist Fathers Worker Athena IGVA Specialist Social Worker Please list any details here: FAIR PROCESSING AND CONSENT SECTIONHere at Lewisham Children and Family Centres we take your privacy very seriously with your consent we will process, retain and store your personal data on behalf of the London Borough of Lewisham in line with the General Data Protection Regulation (GDPR) (EU) 2016/679. Your personal data and contact details will not be shared with any other third party or organisation but may be shared with other Children and Family Centres, and other partnership organisations. You have the following rights regarding your personal data: • The right to withdraw consent at any time • The right to request your personal data is deleted • The right to access to your personal data For more information regarding the use of your personal data please see www.lewishamcfc.org.uk or make a request to: Lewisham.Secure@pre-school.org.uk or Pre-school Learning Alliance, Camelot Centre, 50 Meliot Road, London, SE6 1RY and a copy of the policy will be sent to you.PLEASE CONFIRM THAT THE PARENT HAS GIVEN VERBAL CONSENT FOR THIS REFERRAL. NOTE: THIS REFERRAL WILL NOT BE ACCEPTED WITHOUT EITHER WRITTEN OR VERBAL PARENTAL CONSENT. Either Written or Verbal Consent Has Been Given (Specify Consent from Mother and/or Father Below) ConsentList consent details here: Date Consent Given MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.
