Referrals

CONFIDENTIAL – Frontline Services Referral Form Fields marked * are required. Referral details Date of referral * New referral? Yes No Name of referrer * Name of referrer organisation * Position Telephone number * Email address * Address Has the original safeguarding concern been resolved? Yes No Has the service user consented to the referral? Yes No If no, please explain why Personal circumstances of the service user Yes No Don't know Is the service user over 60 years of age? Does the person have an identified mental health issue or learning disability? Are there any risk factors? (e.g. is the abuse still continuing) Service user demographics Nationality Ethnicity Religion Sexual orientation Additional needs In what local authority does the service user reside? Service user contact details Name * Date of birth Age Gender Address Marital status Preferred safe contact method Select…TelephoneMobileText messageEmailPost Safe contact details Does the safe contact belong to the service user? If no, we cannot contact any third party named unless the service user has given specific consent. Yes No Is it safe to leave a voicemail? Yes No Is it safe to text? Yes No Is it safe to email? Yes No Email address (if safe to email) Details of the abuse Please include where, when and the type of abuse * If you need more space, please email further details to the address at the end of this form. Is the service user still in an abusive situation? Yes No Unknown Is the service user still in contact with the alleged perpetrator? Yes No Unknown Does the service user live with the alleged perpetrator? Yes No Unknown Is the named next of kin the alleged perpetrator? Yes No Unknown Details of the alleged perpetrator Name (if known) Relationship to victim Age Gender Personal circumstances of the alleged perpetrator Yes No Don't know Does the person have an identified mental health issue or cognitive impairment? Are there any additional risk factors? (e.g. drug misuse, alcohol dependency) Are any services supporting them? Are they the main carer for the service user? If services are supporting them (if known), please list them Service user circumstances we need to be aware of Yes No Don't know Diagnosed major depression or anxiety, short-term memory loss, dementia or Alzheimer’s? Hearing impairment Visual impairment History of falls Housebound, poor mobility, or unable to go out alone? Does the person have an identified long-term medical condition? Does the person live on their own? Does the person have a Power of Attorney? Is there a history of self-harm? If the person lives with a dependent, is that dependent considered ‘vulnerable’? Does the person have very little contact with family members? (e.g. once or twice a year) Does the person live with a family member but still feel isolated? Does the person lack confidence to access the community on their own? Is the person able to give consent to having a volunteer? Any known substance abuse issues? Any physical or learning disabilities? Has the person recently retired, or do they have a job? Do they need an interpreter? If you answered yes to any of the above, please give further information Other professionals and comments Professionals and services known to be involved with the service user For example: Safeguarding, Police, Adult Social Services, GP, Community Mental Health Team. Any other comments Submit referral Hourglass Frontline Services Email: referrals@wearehourglass.org Telephone: 080 8808 8141