DAPP Referrals

Referrer Information

My Information

Children

Please provide all details of children, date of birth, gender, if they are living with the client and addresses in the space provided.

I understand that I must provide information pertaining to any current partner I have, or an ex partner I have been abusive towards, as part of my engagement in this service offer.

I understand that such parties will be contacted and offered a service.

If you are referring yourself in relation to historic abuse against an ex partner and have since engaged in a new relationship you are required to provide information of both your ex and current partner.

My Partners / Ex Partners information

WHERE YOU ARE OR HAVE BEEN INVOLVED IN SOCIAL CARE OR PRIVATE LAW PROCEEDINGS PLEASE INCLUDE COPIES OF THE FOLLOWING WHERE AVAILABLE

Please list below any details of forthcoming meetings / reviews / conferences / court dates: 

Client additional needs / risks

Do you have any additional needs that fit into the categories below:

Client employment status: Please tick to indicate

What is your occupation if working:

CONSENT TO STORE AND DISCLOSE INFORMATION ABOUT YOU

 

PLEASE BE AWARE THAT WITHOUT YOUR CONSENT TO THE BELOW WE WILL BE UNABLE TO PROCESS THIS REFERRAL AND YOU WILL BE ILLEGIBLE FOR OUR SERVICE

·       I agree to take part in the My Time DVP Programme and understands that their case is confidential however it will be necessary for the organisation to discuss their case and details with other professional partners / agencies involved for the benefit of information sharing and safeguarding.

·       I understand that there is a parallel service for my partner / ex-partner / family and discussions will take place with those involved.  I agree that I will not interfere with this contact and understand information / reports and this referral will be shared with our integrated support services.

·       Non identifiable data relating to you and your case will be used to evaluate our services.

·       From referral to the service, and up until 7 years after you have completed with the service, the Richmond Fellowship will store information about you, this is a legal requirement for the organisation.

·       Information kept includes – Basic information including D.O.B, contact details, next of kin, professionals working with you, third party information, some information about your background, needs and strengths.  Case notes and reports in relation to the service you have received and any information pertaining to risk.

This information will be sorted on Illy systems which is a secure electronic system we use to record our work with individuals. In order that we understand your needs and support you in the best way possible.  It is also so that we can stay in contact with you and the other people that support you.  Finally, because we want to make sure that as an organisation we comply with the law and best practice in terms of equal opportunities and non-discrimination.

·       I confirm that at the time of this referral being completed I have provided accurate and factual information in relation to my case, and my involvement with other professionals and the law.

I understand that should it transpire at any stage of my engagement with the service I have not been forthcoming in providing information that is truthful or factual the service reserves the right to withdraw their offer to me, and I will not receive reimbursement for this.

·       I understand that I will be required to sign a waiver upon my initial assessment with the service before my suitability is considered.  As part of this waiver I will be required to sign in agreement with the following; I understand that I will not be made privy to any reports written about me, in relation to my engagement, I do however understand that information specific to my engagement and progression can be discussed with me, by a Case Manager In addition, if my report(s) is required by professional agencies or any court proceedings for consideration, requests can be made directly to Richmond Fellowship, and reports will be shared where appropriate.

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