Referral Form To apply for any of our services please complete the form below. If you have any questions about the application process please call us on 01273 612025 or email info@hses.org.ukName of service applied for*Choose from one or more of the four services below: IDVA service (Trans and non-binary people who have experienced domestic abuse) Lotus Domestic Abuse Recovery Programme (Females Who Have Experienced Domestic Abuse) Being Family (Parents of Young Babies) Who’s in Charge? Programme (Parents With Abusive Children or Teenagers) Type of referral* Self-referral Professional referral How did you hear of the programme?Referred by:Name* First Last Job Title* Agency* Email* Telephone*Please confirm:* Client is aware of the service and consents to this referral Have you home-visited the family?* Yes No Continuum of Need:Has the client used our family support service before?* Yes No Does the client have access to a phone to receive ongoing telephone support?* Yes No Do you have access to a phone to receive ongoing telephone support?* Yes No Are there sufficient mobile data/minutes or Wifi available to access weekly Zoom meetings?* Yes No Is there a device that can use the Zoom software?* Yes No Are you working with any other agencies/support services at the moment?* Yes No You said 'yes'. Please provide details:*Client InformationFields not marked with an asterisk are optional. This data is collected for equalities monitoring purposes only.Name* First Last Preferred pronouns* She/her He/him They/them Other Date of birth* Day Month Year Gender Gender assigned at birth Address* Street Address City ZIP / Postal Code Telephone*Email* Preferred method of contact?* Telephone Email Religion Ethnicity* Asian/Asian British: Indian Asian/Asian British: Pakistani Asian/Asian British: Bangladeshi Asian/Asian British: Chinese Asian/Asian British: Other Black, Black British, Caribbean or African: Caribbean Black, Black British, Caribbean or African: African Black, Black British, Caribbean or African: Other Mixed: White and Black Caribbean Mixed: White and Black African Mixed: White and Asian Mixed: Other White: English, Welsh, Scottish, Northern Irish or British White: Irish White: Gypsy or Irish Traveller White: Roma White: Other Other ethnic group: Arab Other Sexuality* Lesbian Gay Heterosexual / straight Bisexual Pansexual Asexual Prefer not to say Other Do you consider yourself to have a disability?* Yes No You said 'Yes'. Please provide details:*Are you a UK national?* Yes No Primary language* Current living arrangements*Employment status*Please give details:Substance misuse/mental health issues*Including diagnosis, treatment and current stability: Are you in a relationship?* Yes No Are you a lone parent?* Yes No Are you living with the person?* Yes No Is this person currently residing with the children?* Yes No Do you feel safe with this person?* Yes No Independent Domestic Violence Advisor SupportOur IDVA service is available as a standalone service for Trans and non-binary people, with optional additional support for females accessing our Lotus Domestic Abuse Recovery programme, and parent/carers accessing our Who's in Charge? programme. Lotus Domestic Abuse Recovery ProgrammeThe Lotus programme is suitable for females who have experienced any form of Domestic Abuse in the past, but are now away from the relationship and consider themselves safe.Please give a summary of historical and current relationship with perpetrator:*How long ago did the relationship end?* How long did the relationship last?* Abuse experiencedChoose as many as are relevant Psychological / mental Financial Sexual Physical Stalking / cyber-stalking Post separation abuse e.g. via child contact Please add any extra detail on points highlighted above.*Do you feel safe at present?* Yes No Have you had contact with the perpetrator within the last three months?* Yes No Have you had more than one intimate partner who was a perpetrator?* Yes No You said 'yes'. How many?*Perpetrator InformationAny info below you have about the perpetrator is only necessary if you have had contact within the last three months. Are you still in contact with the perpetrator? Yes No Are you experiencing post-separation abuse? Yes No Name / AKA* Last AgeAddress* Street Address City ZIP / Postal Code Gender Identity Ethnicity Immigration issues?Substance misuse or mental health issuesIncluding diagnosis and treatment: Disability, literacy or numeracy difficulties?Employment status and detail*Could the perpetrator be a risk to you or the other women on the group if you attend the group?(e.g. staff safety issues, repeat perpetrator, suitable times to call client, honour-based violence, suicide/self-harm) Yes No Being FamilyThe Being Family programme is suitable for parents whose babies are up to one year old.VulnerabilitiesChoose as many as are relevant: Feeling isolated Fretful baby History of domestic abuse Feeling overwhelmed Traumatic birth Mental health difficulties Disability Baby has a disability Difficulties with feeding baby Single parent Insecure housing Insecure finances Recent bereavement Struggling to bond with baby Substance misuse issues Immigration issues Difficulties with reading/writing Physical health problems Please add any extra detail on points highlighted above.Would you like any adjustments to be made to support you to access the Zoom group support?* Yes No You said 'Yes'. Please provide details:*Anything else you feel we should know that can help us to meet the client’s/baby’s needs?Who’s in Charge? ProgrammeSuitable for parents of children aged 8-18 whose behaviour is violent, abusive or seems out of control.Abuse experiencedChoose as many as are relevant: Name calling or aggressive language (verbal abuse) Manipulation or emotional abuse Destruction of property Physical abuse to parent Physical abuse to other family members Financial demands Please add any extra detail on points highlighted above.Have you got more than one child whose behaviour is violent?* Yes No You said 'yes'. How many?*How long has this been going on for? Please detail anything else you may have experienced or would like us to know:Secondary carerFill out this section if you have said that you have a partner and they're currently residing with the children.Name / AKA* Last AgeAddress* Street Address City ZIP / Postal Code Gender Identity Ethnicity Religion Languages Immigration issues?Substance misuse or mental health issuesIncluding diagnosis and treatment: Disability, literacy or numeracy difficulties?Employment status and detail*Children's Information (Under 18)Select 'Add Entry' to add each child one at a time: Name Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Are you or your partner pregnant?* Yes No You said 'Yes'. Please let us know the due date and any other information*Living arrangements of children if different from your home addressContact arrangements with perpetratorAre your children likely to be at home on a weekday morning while you attend the programme?* Yes No Do you have children/stepchildren over 18 living with you or at another address?* Yes No You said 'Yes'. How many?*Are Children's Services involved?* Yes No You said 'Yes'. How are they involved?*Do you have any concerns regarding children?* Yes No You said 'Yes'. What are your concerns?*Do you have any other information?EmailThis field is for validation purposes and should be left unchanged. Δ Getting HelpIndependent Domestic Violence Advisor Support Females Who Have Experienced Domestic Abuse (The Lotus Programme) Parents with Babies (Being Family) Parents with Abusive Children or Teenagers (Who's in Charge?) Referral Form Referrals Donate
