SHROPSHIRE PROFESSIONALS

Referrer Information

Client Information (Male)

Children:

Please provide all details of children below use a separate sheet if required

Please provide details relevant from the following to help outline the needs of the family

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

Client additional needs / risks

CONSENT TO STORE AND DISCLOSE INFORMATION ABOUT YOU

Male receiving DVPP

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

As the professional referring the individual please indicate that you have sought the below consent from the client prior to referral

  • The client agrees 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 partners / agencies involved for the benefit of information sharing.
  • The client understands that there is a parallel service for their partner / ex partner / family and discussions will take place with those involved. The client agrees that they will not interfere with this contact and understand a copy of their referral and assessment report will be shared with the womens services.
  • The individual is aware the programme will be evaluated by a n external university and that their case may form a part of this.
  • From referral to the service, and up until 7 years after an individual has completed wit the service, the Richmond Fellowship will store information about them, 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, some information about your background, needs and strengths. Case notes and reports in relation to the service you have received

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.

Female Partner / Ex Partner Client Information

CONSENT TO STORE AND DISCLOSE INFORMATION ABOUT YOU

Female receiving Support

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

As the professional referring the individual please indicate that you have sought the below consent from the client prior to referral

  • The client agrees to take part in the My Time DVPP Service and understands that their case is confidential however it will be necessary for the organisation to discuss their case and details with other partners / agencies involved for the benefit of information sharing.  If we have any concerns about a current or ex partners behaviour, we shall contact services involved in order to support keeping yourself and your children safe.  This information is kept separate and strictly confidential from any current or ex partners who are accessing the programme.
  • The client understands that there is a parallel service for their partner / ex partner / family and discussions will take place with those involved. The client agrees that they will not interfere with this contact and understand a copy of their partner / ex partner assessment and reports relating to engagement on the programme may be shared with them via the support they receive.
  • The individual is aware the programme will be evaluated by a n external university and that their case may form a part of this.
  • From referral to the service, and up until 7 years after an individual has completed wit the service, the Richmond Fellowship will store information about them, 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, some information about your background, needs and strengths. Case notes and reports in relation to the service you have received

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.

Does the client give their consent to the above? Please tick this box *

© Copyright - DVPP West Midlands Design by uMarketeers