• 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:

  • 1.PERSONAL DETAILS

  • DOB:
     - -
  • Gender Identity:
  • Format: 000 000 0000.
  • Earliest Date of Release:
     - -
  • 0/1000
    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)

  • 0/3000
  • Remand/Sentenced:
  • Date of Next Court Hearing:
     - -
  • 0/3000

  • Prison Probation Officer (if applicable):

  • Format: 000 000 0000.

  • Community Probation Officer:

  • Format: 000 000 0000.
  • Date of Sentencing:
     - -
  • 0/3000
  • 0/3000
  • Estimated Date of Release:
     - -
  • Earliest Date for TR:
     - -
  • 0/3000
  • 0/3000
  • Start Date:
     - -
  • Finish Date:*
     - -
  • Court Ordered/Voluntary:

  • Applicants serving life sentence:

  • 0/3000
  • 0/5000
  • Has the applicant any outstanding offences, orders, compensation or fines?
  • 0/5000

  • 3. Offending History & Factors Relating to Sexual Offending

  • Has the applicant ever been convicted of any of the following offences?

  • Please provide any details of the applicant’s non-sexual offence history:

  • Non-sexual Offence (1)

  • Date of Offence (1)
     - -
  • Date of Conviction (1)
     - -
  • 0/3000

  • Non-sexual Offence (2)

  • Date of Offence (2)
     - -
  • Date of Conviction (2)
     - -
  • 0/3000

  • Please provide any details of the applicant’s sexual or sexually motivated offence history:

  • Sexual Offence (1)

  • Date of Offence (1)
     - -
  • Date of Conviction (1)
     - -
  • 0/1000
  • 0/1000
  • Violence Type (1)
  • 0/1000
  • 0/1000
  • 0/1000
  • 0/1000
  • Applicant Over 18 at Time of Offence (1)
  • 0/1000
  • 0/1000

  • Sexual Offence (2)

  • Date of Offence (2)
     - -
  • Date of Conviction (2)
     - -
  • 0/1000
  • 0/1000
  • Violence Type (2)
  • 0/1000
  • 0/1000
  • 0/1000
  • 0/1000
  • Applicant Over 18 at Time of Offence (2)
  • 0/1000
  • 0/1000

  • 4.RISK ASSESSMENT

  • Date Completed (1)
     - -
  • 0/1000
  • Date Completed (2)
     - -
  • 0/1000
  • Does the applicant have a risk assessment management plan (RAMP)?
  • Is the applicant a risk to themselves or do they have a history of self-harm, suicidal ideation or attempted suicide?
  • 0/2000
  • Are there any particular concerns in regards to risk to staff or volunteers from the applicant?
  • 0/2000

  • * 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 problems?
  • 0/3000
  • Was he/she under the influence of drugs/alcohol when the offence took place?
  • 0/3000
  • Have they previously undergone treatment/received support for substance misuse?
  • 0/3000

  • 6. HEALTH INFORMATION

  • Does the applicant have a medical card?
  • Does the applicant have any specific health needs?
  • 0/1000
  • Is the applicant taking any prescribed medications?
  • 0/1000
  • Does the applicant have any disabilities? (physical, intellectual, learning or sensory)
  • 0/1000
  • Has the applicant ever had a diagnosis and/or treatment for any psychiatric/psychological issues?
  • 0/1000
  • Does the applicant have any health needs that could impact on their accommodation choices?
  • 0/1000
  • Does the applicant have any health needs that could impact on their engagement with PACE programmes?
  • 0/1000

  • Please note: If referring to Safer Lives only - please move to Question 9

  • 7. ADDITIONAL SUPPORT NEEDS

  • Please tick any of the following areas that you would like support with:
  • 0/1000

  • 8. HOUSING

  • 0/3000
  • Is the applicant at risk of homelessness currently or on release from prison?
  • Are there any areas that the applicant cannot live?
  • 0/3000
  • Is the applicant on the housing list?
  • Is the applicant on the homeless list?
  • 0/1000

  • 9. Current Relationships

  • Is the applicant married/in a relationship?
  • Does the applicant live/intend to live with their partner?
  • Does the applicant have children?
  • 0/2000
  • Are social services involved with any children?
  • 0/2000
  • Is he/she/they in contact with his parents?
  • Is he/she/they in contact with his siblings?
  • Are these supportive relationships?

  • 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)
  • Thursday (Online)
  • Friday (Cork)
  • 0/3000

  • Attitude to Offence – full responsibility; partial denial

  • 0/3000
  • 0/3000
  • Previous Experience of Offence-focused or Therapeutic Individual or Group Work:
  • 0/3000

  • Motivation

  • 0/3000

  • 11. CoSA only

  • Motivation

  • Displays genuine commitment to turning their life around by voluntarily entering into a supportive relationship with Volunteers
  • Is committed to creating no more victims

  • Level of participation

  • Commit to being involved for a minimum period of one year on a voluntary basis
  • Communicate openly and honestly with their professional network

  • Outcome

  • 0/3000

  • 12.  SUPPORT INFORMATION

  • 0/5000
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  • 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:

  • Referral Date:
     - -
  • Referring Probation Officer
  • Format: 000 000 0000.

  • 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: