Freedom Programme Referral Form



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Date18.07.2017
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Freedom Programme Referral Form
Return to: Freedom Administrator PO Box 174, Margate Kent CT9 4GA 01843 290891 heather.hunter-whitehouse@oasisdaservice.org

Some points for consideration when you discuss the group with women:



  • Do not discuss in front of her partner or children

  • Ensure that she understands that she should not tell anyone what the group is for - this is to protect herself and others attending.

  • Attendance on the programme is completely voluntary and no agency should try to persuade a woman to attend a programme if she does not feel ready to, or does not want to.


First name:


Surname:

Address:

Postcode:

DOB:
Can we write to you at this address?
Yes /No
Safe address for mail if different from above:

Are you living with the perpetrator?
Further Details:

Yes / No
Telephone numbers:


Mob:
Home:
Is it okay for us to phone you?
Is it ok to leave a message on your home answer phone?
Is it ok for us to leave a message on your Mobile answer phone?


Yes / No

Yes / No
Yes / No

If no, is there some one that we can safely pass a message onto?
Name
Phone
Do you have children under five who need a place in the crèche?
Child’s name:
Is any child(ren) subject to CAF / CHIN /CP arrangements?

Yes / No



DOB:
Yes / No

Special Needs:
Details:

Are there any other agencies involved with your family?

Yes / No
Name



Address

Phone

School


Health Visitor


Social Worker

Drug/Alcohol Worker

Police

Others:

Has a DASH risk assessment been completed? Yes /No


If Yes give details:

Transport required

Yes /No
Do you have a disability?


If yes details:

Yes / No
What is your ethnicity?


What is your employment status?

Full time / Part time / Self-employed / unemployed /

Sick or Disabled / Student/

Retired / Other ……………



Any Additional Info e.g. description of current circumstances


Referred by Agency Yes / No

Self-referral Yes / No
Contact person:


Date:
Organisation:


Phone:
All information on this form is treated with the strictest confidence and is only passed on to another agency on a need to know basis. If issues arise that involve child protection, criminal or legal matters these will need to be passed on to the appropriate authority.
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