Referral Form - Domestic Abuse Recovery Programmes

Our policy requires that rehabilitation only begins once all risk factors have
been conclusively mitigated.

To ensure that clients are stable and prepared for recovery, we require a risk assessment and safety plan with each referral. Please send this to our Head of HR - Zariq Hanif zariq.hanif@honourthywomangroup.org

What satisfies our recovery criteria:

• Comprehensive Risk Mitigation:
Every aspect of the client’s situation (physical, emotional, financial, and
relational) must be free from residual risks.

• Sustainable Safety Provisions:
There must be clear evidence of enduring safety measures and supportive
networks that ensure long-term independence.

• Formal Verification:
A structured checklist, completed and verified by a trained specialist, confirms
that all potential risks have been addre

Name of Organisation*

Contact Person*

Job Title/Role*

Email*

example@example.com

Contact Number*

Full Name of Client*

Date of Birth*

Date

Address*

Contact Number*

Email*

example@example.com

Preferred Contact Method (e.g., phone, email)*

Safe Times to Contact*

Describe your client?*

In a domestic abuse relationshipIs experiencing post relationship abuseAbusive relationship has ended and is ready for recovery

Our programmes are designed to support individuals who are actively seeking to move forward from experiences of abuse, including providing guidance for their children.

At this time, we feel your client may not be ready to engage with our services. For specialist support tailored to their current needs, we recommend reaching out to Gloucestershire Domestic Abuse Support Services (GDASS), who offer a wide range of resources. More information can be found here:

https://www.gdass.org.uk/support-for-professionals/.

We appreciate your commitment to supporting your client, and if further guidance is needed, we are happy to assist where possible.

Is the Client Currently in a Safe Environment?*

YesNo

Does the Client Have Children?*

YesNo

Are There Any Immediate Risks to Their Safety or That of Their Children?*

YesNo

Child's Name

First & surname

Date of Birth

Date

Name of School

School Address

Contact Person at School if applicable

Contact Number for School

Are There Any Concerns Regarding the Child's Behaviour or Academic?

YesNo

Are school staff aware of the domestic abuse situation?

If yes, has any action been taken to support the child (e.g., counselling, peer groups)?

Is the child receiving any additional School-Based or External Support?

2nd Child's Name

Date of Birth

Date

Name of School

School Address

Contact Person at School if applicable

Contact Number for School

Are There Any Concerns Regarding the Child's Behaviour or Academic?

YesNo

Are school staff aware of the domestic abuse situation?

If yes, Has any action been taken to support the child (e.g., counselling, peer groups)?

Is the Child Receiving Any Additional School Based or External Support

3rd Child's Name

Date of Birth

Date

Name of School

School Address

Contact Person at School if applicable

Contact Number for School

Are There Any Concerns Regarding the Child's Behaviour or Academic?

YesNo

Are school staff aware of the domestic abuse situation?

If yes, has any action been taken to support the child (e.g., counselling, peer groups)?

Is the Child Receiving Any Additional School Based or External Support?

Have Any Other Agencies Been Involved Previously?*

YesNo

If yes, Organisation(s)?

Nature of Support Provided:

Please provide a brief overview of the circumstances that have led to this. For example, emotional wellbeing, safety, parenting difficulties, behavioural issues, etc.

Are Any Other Organisations or Services Currently Supporting the Family?*

YesNo

If yes, please specify: Name of Organisation(s): Name of Contact Person(s): Type of Support Provided (e.g., legal aid, housing assistance, therapeutic services):

Have There Been Any Collaborative Efforts Between Agencies? If yes, please briefly outline how collaboration has supported the family.*

Does the Child Display Any Signs of Distress? For example: withdrawal, anxiety, aggression, difficulty concentrating. *

Has the Child Expressed Their Feelings About the Domestic Abuse?*

Has the Child Previously Participated in Any Trauma-Focused Programmes?*

YesNo

Are There Specific Recovery Interventions That May Benefit the Child? For example: play therapy, art therapy, mindfulness exercises.*

YesNo

Does the Child Feel Safe at Home, in School, and in the Community?*

YesNo

If no, please elaborate.

Are There Any Current Concerns Regarding the Child's Living Environment?*

YesNo

If yes, please elaborate.

Has the Mother Previously Been Offered Support from Other Organisations?*

YesNo

If yes, Which organisations or services were involved? What type of support was offered?

Has the Mother Declined Any Support?*

YesNo

If yes, Do you know the reasons for declining support? Examples may include: - Feeling overwhelmed by too many service providers. - Fear or mistrust of external organisations. - Not understanding the benefits of the support offered. - Practical barriers, such as time constraints or childcare

Are There Steps That Could Help Her Engage with Future Services? For example: Tailored communication approaches to build trust. Clear explanations of how the services could benefit her and her family. Addressing practical barriers, such as providing childcare or flexible scheduling.*

Is the Client Ready to Engage with our Recovery Programmes?*

YesNo

Has the Client Expressed Willingness to Participate in Recovery Activities?*

YesNo

Does the Client Have a Support Network They Can Rely On?*

YesNo

If yes, Please provide details.

Has a Safety Plan Been Put in Place or Discussed?*

YesNo

Are There Any Cultural or Religious Requirements That Should Be Considered?*

YesNo

Does the Client or Child Have Any Disabilities or Special Needs?*

YesNo

If yes, Please outline what accommodations may be required.

Any Further Observations or Relevant Information: Please include any insights from school staff, healthcare professionals, etc.

Referring Agency Declaration / confirm that / have explained the purpose of this referral to the client, and they have given their consent to participate in our Domestic Abuse Recovery Programmes.

Referring Person's Signature*

Date*

Date