Prevention Services Referral Form

REFERRAL ELIGIBILTY CRITERIA		CoSA	Foothold	Safer Lives
Offending background Harmful sexual conviction.	Hold a conviction or have a history of sexual harmful offending behaviour.	☑	☑	☑
Probation referral only	PACE prevention services are restricted to probation officer referral only	☑	☑	☑
Age	Aged 23 years or over - In exceptional cases, age from 21+ may be considered.	☑	☑	☑
	Aged 18yrs or older	❌	☑	☑
	Note – applicants that committed the offence when they were under 18yr will be assessed on case-by-case basis
Attitudes & beliefs	Admits to committing the sexual harmful behaviour	☑	N/A	☑
Risk	Medium to High-risk clients on RM 2000	☑	☑	☑
Status	Is under the Supervision of the Probation Service	☑	☑	☑
PACE Foothold Service Accommodation	PACE Foothold accommodation service is restricted to applicants who are/or at risk of homelessness	N/A	☑	N/A
Arson	For applicants that hold a conviction for Arson, contact PACE for a specific risk assessment prior to completing referral.	!	!	!
Reside	Foothold applicants are to live in the greater Dublin area/50km vicinity	N/A	☑	N/A
Need	Have a high need for social support	☑	☑	N/A
*For referral enquiries, please contact the service directly prior to completing form. (Contact details at end)

Please tick which service(s) you are making the referral to:

Safer Lives ¹Foothold²CoSA³
1.PERSONAL DETAILS
Name

First NameLast Name
Alias name
D.O.B:

DayMonthYear
Age
Nationality:
Gender Identity:

MaleFemaleOther
Contact No.:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
If in custody state which Prison:
Earliest Date of Release:
If in custody indicate area/address to which the client is being released:
1. The Safer Lives treatment program is designed to support men who have engaged in harmful sexual behaviour, it is an offense-focused, strengths- based intervention that aims to reduce risk. SL also assess female offenders for individual work.
2. The Foothold Floating Support Service provides intensive outreach, one-to-one support programmes that works with high-risk and high-need clients to address their complex needs.
3. CoSA (A Circle of Support and Accountability) is made up of an Inner Circle of 4-6 volunteers meeting with the client once a week who are supported by an Outer Circle of professionals who are working with the client.

2.LEGAL STATUS (e.g., TR, Full Release, PRSO, PSSSO etc)
Current Offence(s):
RemandSentenced
Date of next Court hearing:
Purpose of next court hearing:
Prison Probation Officer (if applicable):
Phone:
Please enter a valid phone number.
Email:
example@example.com
Community Probation Officer:
Phone:
Please enter a valid phone number.
Email:
example@example.com
Date of sentencing:

DayMonthYear
Sentence:
Any relevant conditions of Sentence:
Estimated date of release:

DayMonthYear
Earliest date for TR:

DayMonthYear
Conditions of release:
Length of supervision order:
Start date:

DayMonthYear
Finish date:*

DayMonthYear
Court ordered Supervision orderVoluntary Supervision order
Applicants serving life sentence:
Parole Board current recommendations:
Details of any previous Parole decisions and instances of returns:
Has the applicant any outstanding offences, orders, compensation or fines?

YesNoDon’t know
Details

3. Offending History & Factors relating to Sexual Offending
How many times has the applicant been in prison (including this time)?
Has the applicant ever been convicted of any of the following offences?

ArsonHarmful Sexual OffenceDrug DealingDrug TraffickingViolenceOrganised Crime OffenceHate CrimesManslaughterMurder
Please provide any details of the applicant’s non-sexual offence history:
Previous Non-sexual Offence History
Details of sexual or sexual motivated offences, starting with current/most recent. (incl. date of conviction, victim gender, age, relationship to applicant)

4.RISK ASSESSMENT
Does the applicant have a risk assessment management plan (RAMP)?

YesNo
Is the applicant a risk to themselves or do they have a history of self-harm, suicidal ideation or attempted suicide?

YesNo
If yes, please give details:
Are there any particular concerns in regards to risk to staff or volunteers from the applicant?

YesNo
If yes, please give details:
* If low RM and risk relevant factors are present, discuss with SPO and agree to complete the Stable to capture those risk relevant issues, then if moderate or high on the Stable you can refer.

5.DRUG & ALCOHOL MISUSE
Does the applicant have any substance misuse problem?

YesNoDon`t know
If yes, please provide details:
Was he/she under the influence of drugs/alcohol when the offence took place?

YesNoDon`t know
If yes, please provide details:
Have they previously undergone treatment/received support for substance misuse?

YesNoDon’t know
If yes, please give details:

10. Safer Lives only
Attendance: Able to Travel to Co. Dublin / Co. Cork (indicate preference)

Available one day a week (tick all that apply):
Tuesday (Dublin)

YesNo
Thursday online

YesNo
Friday (Cork)

YesNo
Any other issue that may impact attendance? (e.g., homeless on release, unclear where they will be residing)
Attitude to Offence – full responsibility; partial denial
Record applicant’s description of his harmful sexual behaviour.
Describe the applicant’s attitude to their offending and level of responsibility taken
Previous Experience of Offence-focused or Therapeutic Individual or Group Work:

YesNoDon`t know
If yes, please provide details:
Motivation
Describe the applicant’s motivation to take part in the Safer Lives Programme?

11. CoSA only
Motivation
Display genuine commitment to turning their life around by voluntarily entering into a supportive relationship with Volunteers

YesNo
Is committed to creating no more victims

YesNo
Level of participation
Commit to being involved for a minimum period of one year on a voluntary basis

YesNo
Communicate openly and honestly with their professional network

YesNo
Outcome How might a CoSA benefit the applicant?

12. SUPPORT INFORMATION
Please provide a synopsis of relevant aspects from any psychological report; Parole Board report and any evaluations, assessments, carried out whilst in Prison, to direct PACE’s support, treatment & advocacy for the applicant if accepted to PACE. Note: Please provide signed consent form from the applicate to share any support documents you have attached.
Cancelof
Referral Inquires Contact Details: prevention@paceorganisation.ie

PART 2. DECLARATION
By submitting this form, you are confirming that you have fulfilled the obligations placed on the collection and processing of personal and special category personal data as outlined by GDPR and that the data submitted to PACE in this form has been collected and processed in compliance with GDPR.

Declaration

I have completed the referral form and obtained my clients consent to submit the details included on this completed form.

Referral Agent:
Signed:

Powered by Jotform SignClear
Date:

DayMonthYear
Date
Referring Probation Officer

YesNo
Prison or community based in:
Email:
example@example.com
Contact telephone number:
Please enter a valid phone number.
Staff will make contact to confirm receipt of referral form within 3 working days. PACE will review referrals and notify referring probation officer of outcome.

*Submit online via PACE website or Probation portal.
Should be Empty:

1.PERSONAL DETAILS