Yuva West Midlands

Referrer Information

Client Information (Perpetrator)

Who Else Lives In The Household?

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

YP receiving YUVA

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.

Does the client give their consent to the above?  TICK BOX HERE

GUIDANCE:

  • If a young person is under 16, we require consent form from the parent/carer before accepting the referral
  • If a young person is over 16, please contact young person for consent and inform parent before accepting the referral
  • Before we undertake work with the young person, we ask that the parent/carer engages in a phone consultation (1-2 sessions) to allow us to obtain an overview of the parents perspective, risk and any safeguarding concerns. Parent consultation will be completed with another member of the Yuva team.

 

It is important to advise Yuva if a family is in or will be in court proceedings and at what stage, so that we can discuss expectations around reporting on outcomes with the family.

HIGHLY CONFIDENTIAL

CONSENT TO STORE AND DISCLOSE INFORMATION WITH DVPP & FEMALE SERVICES

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

·       The client understands that information stored is confidential however it will be necessary to discuss their details with other partners / agencies involved for the benefit of information sharing. If we have any concerns about their current/ex partner’s behaviour, we shall contact services involved in order to help keep yourself and your children safe. This information is kept separate and strictly confidential from current/ex partners accessing the programme.

·       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?  TICK BOX HERE

Victim Information (parent/carer)

© Copyright - DVPP West Midlands Design by uMarketeers