 
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:
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Do not discuss in front of her partner or children
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Ensure that she understands that she should not tell anyone what the group is for - this is to protect herself and others attending.
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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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