Make a referral: Police

Make a referral: Police
Has this victim been assessed as a HIGH risk victim on Athena?*

YesNo
You are not required to continue with this referral to COMPASS. Assessment by COMPASS is not required for cases already assessed as HIGH.

HIGH risk cases are sent automatically to MARAC via Athena, but we ask that you refer HIGH directly to the IDVAs.

For Southend:

IDVA: idva.southend@safesteps.cjsm.net

For Brentwood, Basildon, Castle Point, Epping, Harlow, Rochford and Thurrock

IDVA: idva.referrals@changingpathways.cjsm.net

For Braintree, Chelmsford, Colchester, Maldon, Tendring and Uttledford

IDVA: idva.referrals@nextchapter.cjsm.net
Referrer details
Please tick box to show consent has been given to make this referral*

Yes consent has been given by victim
How did you obtain consent?*
Your name*

First NameLast Name
Collar number*
Team/Dept
Contact number*

Area CodePhone Number
Email*
example@example.com
Sergeant or Supervising Officer extension number*
Ext. Number
Are you the OIC in this case?

YesNo
OIC name

First NameLast Name
OIC collar number
OIC team
OIC contact number

Area CodePhone Number
OIC email
example@example.com
Current victim risk grading on Athena?*

MediumStandard
Victim contact information
Name*

First NameLast Name
Alias
What do they like to be called?
Date of birth*

DayMonthYear
Current Address

Street Address

Street Address Line 2

CityCounty

Postcode
Address fled to (if different)

Street Address

Street Address Line 2

CityCounty

Postcode
District*
District of origin (if different)
Current accommodation type
If other for current accommodation, please complete
Anything else we need to know about the current address
Victim contact information
Phone Number*

Area CodePhone Number
Safe to call?*

YesNo
Safe to text?*

YesNo
Email
example@example.com
Safe to contact by email?

YesNo
Anything else that can help us make contact with the victim safely?
Accessibility requirements
Does this victim have any accessibility requirements (for example hearing loop, braille documents)
If yes to accessibility requirements, please provide details
Does this victim require an interpreter?*
If yes to requiring an interpreter, what language does this victim speak?
Victim equalities monitoring
How would this victim describe their gender?*
Is their current gender different to the sex they were assigned at birth?
Do they consider themselves to have any kind of disability? (please tick any that apply)

PhysicalLearningMental HealthDeaf/hearing impairedBlind/visually impairedSomething elseDon't knowNone
If 'something else' to 'do they consider themselves to have any kind of disability?' please give detail
How would they describe their ethnicity?
If 'other' selected on 'How would they describe their ethnicity?' please give detail
What is their sexual orientation?
If 'Something else' for 'What is their sexual orientation?' please give detail
Victim support needs/vulnerabilities
Please tell us more about any support needs the victim may have:

Mental Health e.g. diagnosis, key worker details, prescribed medication.Substance misuse e.g. use of drugs or alcohol as a way of coping, engaging with treatment services.Physical Health e.g. health conditions, mobility issues.Offending e.g. ever been arrested or convicted of an offence, nature of the offending.
More Mental Health detail
More Substance misuse detail
More Physical health detail
More Offending detail
Are they pregnant?
When are they due?
Children
How many children (18 years or under) does the person being referred have?*
Child 1 name*

First NameLast Name
Child 1 date of birth*

DayMonthYear
Child 1 gender?
Child 1 address, if different from victim

Street Address

Street Address Line 2

CityCounty

Postcode
Does the suspect have parental responsibility for child 1?
Child 1, school attended?
What contact does the suspect have to child 1?
Are social services involved in this case? (Please give details)
Name of social worker for child 1 (if relevant)
Child 2 name*

First NameLast Name
Child 2 date of birth*

DayMonthYear
Child 2 gender?
Child 2 address, if different from victim

Street Address

Street Address Line 2

CityCounty

Postcode
Does the suspect have parental responsibility for child 2?
Child 2, school attended?
What contact does the suspect have to child 2?
Are social services involved in this case? (Please give details)
Name of social worker for child 2 (if relevant)
Child 3 name*

First NameLast Name
Child 3 date of birth*

DayMonthYear
Child 3 gender?
Child 3 address, if different from victim

Street Address

Street Address Line 2

CityCounty

Postcode
Does the suspect have parental responsibility for child 3?
Child 3, school attended?
What contact does the suspect have to child 3?
Are social services involved in this case? (Please give details)
Name of social worker for child 3 (if relevant)
Child 4 name*

First NameLast Name
Child 4 date of birth*

DayMonthYear
Child 4 gender?
Child 4 address, if different from victim

Street Address

Street Address Line 2

CityCounty

Postcode
Does the suspect have parental responsibility for child 4?
Child 4, school attended?
What contact does the suspect have to child 4?
Are social services involved in this case? (Please give details)
Name of social worker for child 4 (if relevant)
Child 5 name*

First NameLast Name
Child 5 date of birth*

DayMonthYear
Child 5 gender?
Child 5 address, if different from victim

Street Address

Street Address Line 2

CityCounty

Postcode
Does the suspect have parental responsibility for child 5?
Child 5, school attended?
What contact does the suspect have to child 5?
Are social services involved in this case? (Please give details)
Name of social worker for child 5 (if relevant)
Child 6 name*

First NameLast Name
Child 6 date of birth*

DayMonthYear
Child 6 gender?
Child 6 address, if different from victim

Street Address

Street Address Line 2

CityCounty

Postcode
Does the suspect have parental responsibility for child 6?
Child 6, school attended?
What contact does the suspect have to child 6?
Are social services involved in this case? (Please give details)
Name of social worker for child 6 (if relevant)
Child 7 name*

First NameLast Name
Child 7 date of birth*

DayMonthYear
Child 7 gender?
Child 7 address, if different from victim

Street Address

Street Address Line 2

CityCounty

Postcode
Does the suspect have parental responsibility for child 7?
Child 7, school attended?
What contact does the suspect have to child 7?
Are social services involved in this case? (Please give details)
Name of social worker for child 7 (if relevant)
Child 8 name*

First NameLast Name
Child 8 date of birth*

DayMonthYear
Child 8 gender?
Child 8 address, if different from victim

Street Address

Street Address Line 2

CityCounty

Postcode
Does the suspect have parental responsibility for child 8?
Child 8, school attended?
What contact does the suspect have to child 8?
Are social services involved in this case? (Please give details)
Name of social worker for child 8 (if relevant)
Child 9 name*

First NameLast Name
Child 9 date of birth*

DayMonthYear
Child 9 gender?
Child 9 address, if different from victim

Street Address

Street Address Line 2

CityCounty

Postcode
Does the suspect have parental responsibility for child 9?
Child 9, school attended?
What contact does the suspect have to child 9?
Are social services involved in this case? (Please give details)
Name of social worker for child 9 (if relevant)
Child 10 name*

First NameLast Name
Child 10 date of birth*

DayMonthYear
Child 10 gender?
Child 10 address, if different from victim

Street Address

Street Address Line 2

CityCounty

Postcode
Does the suspect have parental responsibility for child 10?
Child 10, school attended?
What contact does the suspect have to child 10?
Are social services involved in this case? (Please give details)
Name of social worker for child 10 (if relevant)
Suspect(s)

Information about the suspect(s), if known:
How many suspects are involved in this case? *
Name (suspect 1)*

First NameLast Name
Alias (suspect 1)
Relationship to victim (suspect 1)
Address (suspect 1)

Street Address

Street Address Line 2

CityCounty

Postalcode
What is this address? (suspect 1)

Usual addressBailed to address
Date of Birth (suspect 1)

DayMonthYear
Occupation (suspect 1)
Notes about the suspect i.e. bail address, bail conditions, drug/alcohol issues, use of weapons, known warning markers, military, hobbies/interests of concern (suspect 1)
Name (suspect 2)*

First NameLast Name
Alias (suspect 2)
Relationship to victim (suspect 2)
Address (suspect 2)

Street Address

Street Address Line 2

CityCounty

Postalcode
What is this address? (suspect 2)

Usual addressBailed to address
Date of Birth (suspect 2)

DayMonthYear
Occupation (suspect 2)
Notes about the suspect i.e. bail address, bail conditions, drug/alcohol issues, use of weapons, known warning markers, military, hobbies/interests of concern (suspect 2)
Name (suspect 3)*

First NameLast Name
Alias (suspect 3)
Relationship to victim (suspect 3)
Address (suspect 3)

Street Address

Street Address Line 2

CityCounty

Postalcode
What is this address? (suspect 3)

Usual addressBailed to address
Date of Birth (suspect 3)

DayMonthYear
Occupation (suspect 3)
Notes about the suspect i.e. bail address, bail conditions, drug/alcohol issues, use of weapons, known warning markers, military, hobbies/interests of concern (suspect 3)
Name (suspect 4)*

First NameLast Name
Alias (suspect 4)
Relationship to victim (suspect 4)
Address (suspect 4)

Street Address

Street Address Line 2

CityCounty

Postalcode
What is this address? (suspect 4)

Usual addressBailed to address
Date of Birth (suspect 4)

DayMonthYear
Occupation (suspect 4)
Notes about the suspect i.e. bail address, bail conditions, drug/alcohol issues, use of weapons, known warning markers, military, hobbies/interests of concern (suspect 4)
Name (suspect 5)*

First NameLast Name
Alias (suspect 5)
Relationship to victim (suspect 5)
Address (suspect 5)

Street Address

Street Address Line 2

CityCounty

Postalcode
What is this address? (suspect 5)

Usual addressBailed to address
Date of Birth (suspect 5)

DayMonthYear
Occupation (suspect 5)
Notes about the suspect i.e. bail address, bail conditions, drug/alcohol issues, use of weapons, known warning markers, military, hobbies/interests of concern (suspect 5)
Reason for referral
Athena Reference Number*
e.g. ##/######/##
Date of incident*

DayMonthYear
Date
Incident Report detail*
It would be helpful to know if there are any specific support needs i.e. housing, court orders, child contact, immigration etc.?
Are there any known risks to working with this victim?
I confirm the victim has consented to this referral*

Yes
I confirm this case is being referred as a STANDARD or MEDIUM risk*

Yes
I confirm I have provided you with Sergeant or Supervising Officer extension number*

Yes
To submit your form please click/tap the 'Submit' button.
Should be Empty:

Make a referral: Police

Referrer details

Victim contact information

Victim contact information

Accessibility requirements

Victim equalities monitoring

Victim support needs/vulnerabilities

Children

Suspect(s)

Reason for referral