HTWG Self Referral-Form

All questions must be answered for this referral to proceed.
Date of Referral*

DayMonthYear
Date
Date of Birth*

DayMonthYear
Date
Client Name*
Ethnicity*
Address (inc. Postcode)*
First Language Is an interpreter required?*
Phone*
Email*
example@example.com
Safest time to contact*
Is case subject to direction via court proceedings or have court timescales?*

Children and Young People - Give details of any children the person who has been harmed has caring responsibilities for or children you live with:

	Name of Child	Relationship to client	Gender	D.O.B	Ethnicity	Disa bility
Child One
Child Two
Child Three
Child Four
Child Five
Child Six
Child Seven
Child Eight

Who do the children live with and what are contact arrangements with parents/carers and family? Give Details or put N/A
Are the children open to Children's Services or subject to any plan? (Children's Social Care or Early Help and Prevention) Give Details or put N/A
Is the relationship past or current?*
If the relationship is a past relationship? Why and when did the relationship end?*

Planned LeaveDue to Children's Services InvolvementLeft in an emergencyOther
If past: Is the relationship likely to resume?*
If past: Where is the person who harmed now and do, they have any contact with you?*
Are there any court orders in place?

Domestic Violence Protection Order/NoticeNon-Molestation OrderRestraining OrderStalking Protection OrderOccupation OrderProhibited Steps Order
If above box ticked, is the person who harmed adhering to this order / has there been any breaches? Give details -
Is the person who caused harm aware you are engaging with our service?*
Are they also aware of this referral?*
Has the person who harmed been referred onto, is currently on or has completed a programme for people who harm?*
If yes, give details.
Have any CURRENT risks to you, your family, or friends been identified .e.g., stalking, threatening? If yes, give details.*
Any further Information to support this referral.*
Do you understand what our programmes are?*
Do you any have mental health or substance use issues?*
If so, have you seek professional help? Please provide their names and contact details.
Do you have a disability or learning need that may mean our programmes provision requires adaptation?*
Do you have signs of emotional impact of the abuse e.g., anxiety, sleep issues / eating issues?*
Have you received any counselling / other therapeutic input? If so, please provide their names and contact details.*
Should be Empty: