Make Amends Agency Referral Form

Agency Referral Form

Referral telephone number 01803 222033
Nature of referral

Criminal JusticeVoluntary/CommunitySchoolChildren's ServicesOther
Date

MonthDayYear
Date
Referrer Contact

First NameLast Name
Organisation
if applicable
E-mail
Phone Number

Area CodePhone Number
Name of person taking responsibility for the harm:

First NameLast Name
Date of birth

MonthDayYear
Date
Main phone number

Area CodePhone Number
Mobile phone number

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Safe Contact details
Does this person have a named *POM, COM or other assigned professional? (please provide name and contact if applicable)
*Prison offeder manager or community offender manager
Is this person subject to the following?

MAPPAMARACPPO
Is there a previous offending history?

YesNo
Is a full risk assessment required for this person?

YesNo
Does this person take accountability / accept responsibility for the harm caused? (if no, restorative justice not likely to be suitable or effective, and we will not be able to proceed with the referral)*

YesNo
What would this person like to achieve/see as an acceptable outcome?
Is there a preference for a male or female practitioner?

YesNoMaleFemale
Has Consent to share information been given? *(if no, we may not be able to proceed with the referral - please see end notes)

YesNo
Main offence/ Details of harm caused
Crime Number (if applicable)
Date Occurred

MonthDayYear
Date
Offence:
Brief description of specific harm / damage caused:
Brief description of what happened:
Court Sentence (if applicable)
License conditions/restraining orders/ non-molestation orders
Any Social Services involvement? (if known, please provide details of Social Worker)
Name of person harmed

First NameLast Name
Date of birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Main phone number

Area CodePhone Number
Mobile phone number

Area CodePhone Number
Email address
example@example.com
Safe contact details:
What would this person like to achieve/see as an acceptable outcome?
Is there a preference for a male or female practitioner?

YesNoMaleFemale
Has Consent to share information been given? *(if no then we may not be able to proceed with the referral - please see end notes)

YesNo
Notes on completion

You MUST have consent from the party you are referring on behalf of.

If this is a non-reported crime referral, then you must have consent from BOTH parties.

N.B. Sensitive and Complex cases may be subject to a multi-agency meeting.
Should be Empty:

Agency Referral Form

Main offence/ Details of harm caused