WWCSC Referral Form Step 1 of 5 0% SECTION A: REQUIRED INFORMATION ABOUT THE REFERRER and the FAMILY BEING REFERREDREFERRER’S DETAILSDate of Referral* DD slash MM slash YYYY Name of Professional making the referral* Organisation / Team* Telephone Number*Email* PARENT/CARERFIRST NAMESURNAMEM/FRELATION TO CHILDD.O.BETHNICITYRELIGIONNHS NUMBER CHILD (Please list all children in the family)FIRST NAMESURNAMEM/FD.O.BSCHOOLCPP/CINETHNICITYRELIGIONNHS NUMBER Use the plus button at the end of the line to add more childrenAddress and Postcode of Family*Phone Number* ANY OTHER SIGNIFICANT MEMBERS OF THE HOUSEHOLD OR FAMILYNAMERELATIONSHIP TO FAMILYADDRESS and POSTCODETEL / MOBILEE-MAILSAFE TO CONTACT?SAFE CONTACT NOTES PROFESSIONALS WORKING WITH FAMILYAre Children’s Social Care involved with this client/family?Please indicate the nature of their involvement in the field below. Name and contact details of Social WorkerNameTelE-Mail Are Early Help involved with this client / family?* Yes No Unknown Is there a SOS / EHA / TAF plan for this family?* Yes No Unknown Name and contact details of Family Support Worker:NameTelE-Mail Are the Police involved with this client / family?* Yes No Unknown Name and contact details of Police Officer involvedNameTelE-Mail Is there an IDVA or IGVA involved with this client / family?* Yes No Unknown Name and contact details of IDVA or IGVA:NameTelE-Mail Please list anyone else involved in supporting the client / family. SECTION B: REFERRAL DETAILSPRESENTING REASON FOR REFERRAL*What has led to this referral? What are you worried about and why? (Please include family history, context and impact on child of current circumstances)WHY ARE YOU REFERRING TO US*Please explain what kind of support you feel we can offer that would benefit the family and how you will know when things have changed. Note: if domestic abuse features as a presenting issue, please ensure that you complete SECTION C. Do any of the family members have a special need, physical disability or mental health needs?*YesNoUnknownIf Yes, please give details belowHave there have been any issues relating to violence/abuse within the family?*YesNoIf yes, then please complete SECTION C on the proceeding page. Please click Next to proceedSECTION C: REFERRALS FOR THE COMMUNITY GROUPS PROGRAMME, THE FREEDOM PROGRAMME AND/OR WHERE DOMESTIC ABUSE HAS BEEN EXPERIENCED The Community Groups ProgrammeThe Freedom Programme The Community Groups Programme is a twelve-week therapeutic programme for women and children who have experienced domestic abuse. It seeks to enable the recovery process and aims to: • Validate the children’s experiences. • Reduce the self-blame that is commonly associated with children experiencing abuse. • Develop a child-appropriate safety plan. • Manage appropriate and inappropriate expressions of emotion. • Enhance the mother-child relationship. • Enable both the mother and child to heal together.The Freedom Programme is for women who are experiencing or surviving domestic abuse. It usually runs for eleven or twelve weeks (but this may vary depending on your locality) and aims to: • Provide women who are experiencing or surviving domestic abuse with a safe, supportive and friendly environment. • Allow women to recognise the tactics and behaviours of ‘the dominator’ – that is, the tactics that typify a perpetrator of domestic abuse. • Give women the opportunity to build connections with other women. ABOUT THE ABUSERisk level - todayLowMediumHighProfessional JudgementDASH RIC Score123456789101112131415161718192021222324MARACYesNoUnknownIf yes, please indicate outcomes from MARACHas any of the following been experienced? Physical Abuse Stalking / Harassment Financial Abuse Emotional Abuse Honour based violence Coercive control Sexual Abuse Psychological Abuse Forced marriage Are they still in a relationship with the perpetrator of domestic abuse?YesNoUnknownHow long were they in a relationship with the abusive person?< 6 Months6m - 1 Year1-2 Years2-3 Years3-4 Years5-6 Years7-8 Years8-9 Years9-10 Years10-15 Years15+ YearsWhen did the relationship end? Does the perpetrator/alleged perpetrator still reside in the family home?YesNoUnknownIf no longer in the relationship with the alleged perpetrator, is the client currently in a new relationship?YesNoUnknownPlease detail how the child/children have been impacted by the abuse:Please click Next to proceedINFORMATION ABOUT THE PERPETRATOR/ALLEGED PERPETRATOR (IF KNOWN)Name: Relationship to Client: Address:Date of Birth: MM slash DD slash YYYY Does the perpetrator / alleged perpetrator have contact with the children?YesNoUnknownIs there a non-molestation order in place?YesNoUnknownIs there a prohibitive steps order in place?YesNoUnknownIs the perpetrator/alleged perpetrator known to probation services?YesNoUnknownAre there any licence/bail conditions or current proceedings taking place in relation to the Domestic Abuse?YesNoUnknownIf yes, please provide details:If there is more than one alleged perpetrator, please provide additional details below: SECTION D: FAIR PROCESSING AND CONSENT FORM Here 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@eyalliance.org.uk or Early Years Alliance, Camelot Centre, 50 Meliot Road, London, SE6 1RY and a copy of the policy will be sent to you.* I understand that by providing my consent I am confirming I understand how and why my personal data is used and give permission for Lewisham Children and Family Centres to store and update my personal details.* I am a parent/legal guardian of a child/children under the age 16 and give consent for Lewisham and Children Family Centres to store and use my child/children’s personal data for the purposes of the service.* I give permission to Lewisham Children and Family Centres and any relevant partner organisation to contact me regarding services available and my access to them by:Preferences Select All Email Post Telephone (including text messages) PLEASE CONFIRM THAT THE PARENT HAS GIVEN VERBAL CONSENT FOR THIS REFERRAL. NOTE: A REFERRAL WILL NOT BE ACCEPTED WITHOUT EITHER WRITTEN OR VERBAL PARENTAL CONSENT* VERBAL CONSENT HAS BEEN GIVENDate Consent Given:* MM slash DD slash YYYY REFERRER’S NAME:*Please type name Date:* MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
