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Savera UK

Savera UK

Savera UK

Helpline 0800 107 0726

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Savera UK Referral Form (16+)

Please provide as much information and detail as possible. To meet our referral criteria, a person must be at risk or a survivor of: HBA, forced marriage or female genital mutilation (FGM), any other harmful practices or culturally specific harm, domestic abuse related to HBA or trafficking related to HBA. All referrals MUST meet our referral criteria to be accepted.

If you have any problems submitting the referral, please contact us by calling 0800 107 0726.
Date of referral to Savera UK

Referrer Information

Referrer's Line Manager Details

(If you are the main contact/line manager, please put your own details here)

Client Details

Client Date of Birth(Required)
Client Address(Required)
Is an interpreter required (for complex conversations)?
Are they currently practicing it?
Any identified disability?(Required)
Are there any mental health issues that we need to be made aware of?(Required)

Immigration

Are they receiving any support with immigration / asylum support?
Does the client have a solicitor?

Client GP Details

GP Address

Consent & Environment

Has the client given consent for Savera UK to contact them?(Required)
Does the client understand who Savera UK is and what support we provide?
Is it safe to contact the client using information provided?(Required)
Is there a specific time day to make contact?(Required)
Is the client in a safe address?(Required)

Children & Other Family At Risk of Harm

Are there are any children and other family at risk of harm?
What is their date of birth?
Is there a second child or family member at risk of harm?(Required)
What is their date of birth?
Is there a third child or family member at risk of harm?(Required)
What is their date of birth?
Is there a fourth child or family member at risk of harm?(Required)
What is their date of birth?
Is there a fifth child or family member at risk of harm?(Required)
What is their date of birth?
Is there a sixth child or family member at risk of harm?(Required)
What is their date of birth?
Is there a seventh child or family member at risk of harm?(Required)
What is their date of birth?
Is there an eighth child or family member at risk of harm?(Required)
What is their date of birth?
Is there a ninth child or family member at risk of harm?(Required)
What is their date of birth?
Is there a tenth child or family member at risk of harm?(Required)
What is their date of birth?

Perpetrator Information

Do you have information about the perpetrator(s)?
What is their date of birth?
Is there a second perpetrator?
What is their date of birth?
Is there a third perpetrator?
What is their date of birth?
Is there a fourth perpetrator?
Date
Is there a fifth perpetrator?
What is their date of birth?

Harmful Practices Risks

In your professional opinion, do you identify these risks/threats?(Required)
Does the client recognise the risk and threat as HBA/culturally specific abuse?(Required)

Risk Assessment & Other Agencies

Risk Assessments

Has an ‘honour’-based abuse or other risk assessment been completed?
Has a risk management plan been completed?

Multi-Agency Risk Assessment Conference (MARAC)

Has client been referred to MARAC currently or previously? (Please note if no, as the main referrer, you are required to make a referral to MARAC)(Required)
When did MARAC take place?

HBA & Harmful practices Safeguarding Strategy Meetings or any other professional meeting

Has a meeting been held or organised?

Social Services

Has client been referred to Social Services?(Required)
Has a social worker been allocated to this case?(Required)

Police

Any police involvement?(Required)
Has a HBA toolkit been completed?
Police/travel Border Markers?

Other Services

Is the client being supported by other services (this can include statutory and non-statutory)?
Is the client being supported by a second service (this can include statutory and non-statutory)?
Is the client being supported by a third service (this can include statutory and non-statutory)?
Is the client being supported by a fourth service (this can include statutory and non-statutory)?
Is the client being supported by a fifth service (this can include statutory and non-statutory)?

Safeguarding & Safety Planning Measures

(i.e., colleague, friend, family, community member etc.)

Our Funders

Savera UK
151 Dale Street
Liverpool
L2 2AH

General Enquiries: 0330 159 2004

Reg No 1145564
Company No 7564891

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