Horizons Referral Form

Page 1

Has a MARAC referral been completed for this client in relation to this referral? If yes please refer to Victim Support High Risk IDVA Service.

https://bedsdv.org.uk/get-help/victim-support-bedfordshire/

Details of Adult being referred.

Page 2 - Perpetrator details

Contact Details

First Name

Last Name

Date of Birth

Ethnicity

Address details (if it's different from before)

Address Line 1

Address Line 2

City

Postal Code

Are there any substance misuse?

What is the relationship to adult being referred?

Any mental health concerns?

Page 4 - Referrers details

First Name

Last Name

Email

Phone Number

Job Title

Agency

Are there / were there other agencies involved?

YesNo

If yes, please give us details below:

Are they currently involved?

YesNo

Name:

Phone Number

Job Title:

Agency:

Page 5 - Reason for referral (please provide as much information as possible)

Current concerns?
(what has prompted this referral? Please include when last incident happened)

Current relationship status

History of Abuse

Are there any protective orders in place (Civil or Criminal)
Please provide details or a copy of the order

What interventions have been tried or in place?
(i.e. CAF, Graded Care Profile, Social Care Referral, Parenting Programme, etc)

Children's Services current involvement details

Any other information

Have a risk assessment been done?
(if yes, please upload below)

YesNo

Risk Assessment file upload

If yes to any of the above, please let us know:
Status (live/closed), Date of Closure (if applicable), Date of next multi-agency meeting.