(DRAFT - DO NOT USE) Salesforce ACC&TSE Form

REFERRAL ELIGIBILTY CRITERIA		Accommodation	Training and Social Enterprise
Offending Background	Hold a conviction or have a history of offending behaviour.	☑	☑
Age	Be aged 18 years or older.	☑	☑
Homeless/Risk of Homelessness	Referrals to the PACE accommodation service are restricted to men who are homeless or at risk of homelessness.	☑	N/A
Probation Referral Only	PACE accommodation service is restricted to probation officer referrals only.	☑	N/A
Open to Referral Agents & Self-Referral	T&SE is open to probation, community support services, and self-referrals.	❌	☑
Harmful Sexual Conviction	For applications with convictions for harmful sexual behaviour, please refer to the PACE Prevention Services referral form.	⚠️	⚠️
Arson	For applicants that hold a conviction for arson, contact PACE for a specific risk assessment prior to completing the referral.	🔥	🔥

Please tick which service(s) you are making the referral to:
Accommodation (SF map)
Training & Social Enterprise(SF map)
All parts of this form must be completed for probation referral. For non-probation referrals, please skip section 2.
1. PERSONAL DETAILS
Name:

First NameLast Name
DOB:

DayMonthYear
Date
Age:
Nationality:
Contact No:
Please enter a valid phone number.Format: 000 000 0000.
Address:

Street Address

Street Address Line 2

CityCounty

Eircode/PostcodeCountry
If in custody state which Prison:
Prison ID number:
Earliest Date of Release:

DayMonthYear
Date
1: PACE Accommodation Service provides supported transitional accommodation for men leaving prison on a pre and post release basis and also to men in the community under probation supervision that are homeless and in need of support.

2: PACE Training & Social Enterprise project provides a training, education and work experience for adults with criminal convictions or an offending background.

2. Probation Officer to complete ONLY

LEGAL STATUS (e.g. TR, Full Release, PRSO, PSSSO etc)
Current Offence(s):

0/3000
Remand/Sentenced:
Date of next Court Hearing:

DayMonthYear
Date
Purpose of next Court Hearing:

0/3000
Prison Probation Officer (if applicable):
PPO Email:
example@example.com
PPO Phone:
Please enter a valid phone number.Format: 000 000 0000.
Community Probation Officer (if applicable):
CPO Email:
example@example.com
CPO Phone:
Please enter a valid phone number.Format: 000 000 0000.
Date of Sentencing:

DayMonthYear
Date
Sentence

0/2000
Estimated Date of Release:

DayMonthYear
Date
Earliest Date for TR:

DayMonthYear
Date
Conditions of Release

0/3000
Length of Supervision Order:

0/3000
Applicants serving life sentence:
Parole Board Current Recommendations:

0/3000
Details of any previous Parole decisions and instances of returns:

0/3000
Has the applicant any outstanding offences, orders, compensation or fines?
Details of outstanding offences, orders, compensation or fines:
If applicant is being referred from a prison setting, what is their Incentivise Prison Regime level,
Details of Incentivise Prison Regime Level:

0/3000

3. OFFENDING HISTORY

Please provide details of the applicant’s offence history
Current/most recent offence (incl. date of conviction; sentencing outcome)

0/3000
How many times has the applicant been in prison (including this time)?
Has the applicant ever been convicted of any of the following offences?
Violence Used/Intended/Threatened/Planned Details: (e.g., weapon, excessive physical force, false imprisonment):

0/3000
Previous Offence History
Offence (1)
Date of Offence (1)

DayMonthYear
Date
Date of Conviction (1)

DayMonthYear
Date
Sentence Outcome (1) (incl. Probation Orders & Community Services)

0/3000
Offence (2)
Date of Offence (2)

DayMonthYear
Date
Date of Conviction (2)

DayMonthYear
Date
Sentence Outcome (2) (incl. Probation Orders & Community Services)

0/3000

4. RISK ASSESSMENT
Date Completed (1)

DayMonthYear
Date
Risk Assessment Tool (1)
Rating (1)
Details (1) (incl. potential triggers, related risks & protective factors)

0/1000
Date Completed (2)

DayMonthYear
Date
Risk Assessment Tool (2)
Rating (2)
Details (2) (incl. potential triggers, related risks & protective factors)

0/1000
Is the applicant a risk to themselves or do they have a history of self-harm, suicidal ideation or attempted suicide?
Self-harm Details:

0/2000
Is the applicant at risk of violence from others? (incl. if under protected segregated in prison; drug debt intimidation etc)
Risk of Violence from Others Details:

0/2000
Is the applicant likely to pose a community safety concern in PACE services (e.g. victim impact issues in the D17 or D9 areas)?
Community Safety Concern Details:

0/2000

9. 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.

0/5000

10. 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 attached appropriate supporting information and/or reports and obtained my clients consent to submit the details included on this completed form and supporting documents.

Referral Agent:
Referral Agent Name:
Signed:
Referral Date:

DayMonthYear
Referring Probation Officer:
Prison or Community based in:
Referral Type:
Referral Agent Email:
example@example.com
Referral Agent Phone:
Please enter a valid phone number.Format: 000 000 0000.
Should be Empty:

PACE Referral Form