16 and over referral

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 or harmful practices such as forced marriage, female genital mutilation (FGM), conversion ‘therapy’, spiritual abuse or any abuse 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.

Today's date

Referrer Information

First Name(Required)

Last Name(Required)

Role/Job Title(Required)

Relationship To Client

Organisation Referrer Works For(Required)

Team

Telephone Number(Required)

Email(Required)

Referrer's Line Manager Details

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

First Name(Required)

Last Name(Required)

Email(Required)

Telephone(Required)

Risks Identified

Please tick all risks identified(Required)

If 'other' selected, please explain here:

Please provide a brief overview of incidents relating to all of the risks identified:

Client Details

First Name(Required)

Last Name(Required)

Client Date of Birth(Required)

Client Address(Required)

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Client Phone Number(Required)

Other form of contact (e.g email)

Does client consent to direct intervention?(Required)

Does client understand what direct intervention is?(Required)

Please note that it is necessary that clients understand what Savera UK does prior to referral.

Is the client able to safely engage?(Required)

Please note that we are unable to work directly with individuals who are NOT safe to contact

If no, why?(Required)

Please provide details of safe method of contact (time, environment etc)(Required)

Gender(Required)

If other, please state(Required)

Ethnicity(Required)

White(Required)

Mixed/Multiple Ethnic Background(Required)

Asian/Asian British(Required)

Black, African, Caribbean, Black British(Required)

Other Ethnic Group (Arab, any other ethnic group)(Required)

If any other, please state(Required)

Sexual Orientation(Required)

If other, please state(Required)

Transgender(Required)

Relationship Status(Required)

If other, please state(Required)

Religion(Required)

If other, please state(Required)

Disability(Required)

If yes, please provide details(Required)

Are there any mental health issues that we need to be made aware of?(Required)

Yes

Unknown

If yes, please provide details(Required)

Primary Langauge(Required)

Is an interpreter required (for complex conversations)?

Yes

Immigration Status

Recourse to public funds?

Nationality(Required)

Does the client have a solicitor?

Yes

Unknown

What type of solicitor?

If yes, please provide contact details

Please provide solicitor name, firm and contact number

If other, state what type of solicitor and provide contact(s)

Please provide solicitor name, firm and contact number

Client GP Details

GP Name

GP Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

GP Phone

Children & Other Family At Risk of Harm

Are there are any other family members at risk of harm?

First Name

Last Name

What is their gender?

If other, please state(Required)

What is their date of birth?

Are they under the age of 18?

Yes

Unknown

Are they known to Children's Services?

Yes

Unknown

Is client the parent?

Yes

Unknown

If no, what is client's relationship to them?

If other, please state(Required)

What is the risk of harm? Select as many as required

If other, please state

Is there a second family member at risk of harm?(Required)

First Name (Person 2)

Last Name (Person 2)

What is their gender? (Person 2)

If other, please state (Person 2)(Required)

What is their date of birth? (Person 2)

Are they under the age of 18? (Person 2)

Yes

Unknown

Are they known to Children's Services? (Person 2)

Yes

Unknown

Is client the parent? (Person 2)

Yes

Unknown

If no, what is client's relationship to them? (Person 2)

If other, please state (Person 2)(Required)

What is the risk of harm? Select as many as required (Person 2)

If other, please state (Person 2)

Is there a third family member at risk of harm?(Required)

First Name (Person 3)

Last Name (Person 3)

What is their gender? (Person 3)

If other, please state (Person 3)(Required)

What is their date of birth? (Person 3)

Are they under the age of 18? (Person 3)

Yes

Unknown

Are they known to Children's Services? (Person 3)

Yes

Unknown

Is client the parent? (Person 3)

Yes

Unknown

If no, what is client's relationship to them? (Person 3)

If other, please state (Person 3)(Required)

What is the risk of harm? Select as many as required (Person 3)

If other, please state (Person 3)

Is there a fourth family member at risk of harm?(Required)

First Name (Person 4)

Last Name (Person 4)

What is their gender? (Person 4)

If other, please state (Person 4)(Required)

What is their date of birth? (Person 4)

Are they under the age of 18? (Person 4)

Yes

Unknown

Are they known to Children's Services? (Person 4)

Yes

Unknown

Is client the parent? (Person 4)

Yes

Unknown

If no, what is client's relationship to them? (Person 4)

If other, please state (Person 4)(Required)

What is the risk of harm? Select as many as required (Person 4)

If other, please state (Person 4)

Is there a fifth family member at risk of harm?(Required)

First Name (Person 5)

Last Name (Person 5)

What is their gender? (Person 5)

If other, please state (Person 5)(Required)

What is their date of birth? (Person 5)

Are they under the age of 18? (Person 5)

Yes

Unknown

Are they known to Children's Services? (Person 5)

Yes

Unknown

Is client the parent? (Person 5)

Yes

Unknown

If no, what is client's relationship to them? (Person 5)

If other, please state (Person 5)(Required)

What is the risk of harm? Select as many as required (Person 5)

If other, please state (Person 5)

Perpetrator Information

Do you have information about the perpetrator(s)?

Yes

Unknown

First Name

Last Name

What is their gender?

What is their date of birth?

Relationship to client (Perp 1)

If other, other female relative or other male relative, please state

Is there a second perpetrator?

Yes

Unknown

First Name

Last Name

What is their gender?

What is their date of birth?

Relationship to client (Perp 2)

If other, other female relative or other male relative, please state

Is there a third perpetrator?

Yes

Unknown

First Name

Last Name

What is their gender?

What is their date of birth?

Relationship to client (Perp 3)

If other, other female relative or other male relative, please state

Is there a fourth perpetrator?

Yes

Unknown

First Name

Last Name

What is their gender?

Date

Relationship to client (Perp 4)

If other, other female relative or other male relative, please state

Is there a fifth perpetrator?

Yes

Unknown

First Name

Last Name

What is their gender?

What is their date of birth?

Relationship to client (Perp 5)

If other, other female relative or other male relative, please state

Risk Assessment & Other Agencies

Risk Assessments

Has a DASH-RIC, MeRIT or other risk assessment been completed?

Yes

Unknown

If yes, please provide score or further details.

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)

Yes

Unknown

When did MARAC take place?

If already heard for latest incident, please provide main actions:

Have police completed HBA kit/biometrics

Are Border Force markers in place?

Any other police involvement?

Please provide any Police Log Numbers (if known)

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

Heard at any multi-agency meeting?

Yes

Unknown

If yes, what date did the meeting take place

If yes, please provide main actions

Other professional involvement

Is the client being supported by other services (this can include statutory and non-statutory)?

Yes

Unknown

Service Name

Full Name of Contact at Service

Contact Email

Contact Telephone

Reason for Referral

Is the client being supported by a second service (this can include statutory and non-statutory)?

Yes

Unknown

Service Name

Full Name of Contact at Service

Contact Email

Contact Telephone

Reason for Referral

Is the client being supported by a third service (this can include statutory and non-statutory)?

Yes

Unknown

Service Name

Full Name of Contact at Service

Contact Email

Contact Telephone

Reason for Referral

Is the client being supported by a fourth service (this can include statutory and non-statutory)?

Yes

Unknown

Service Name

Full Name of Contact at Service

Contact Email

Contact Telephone

Reason for Referral

Is the client being supported by a fifth service (this can include statutory and non-statutory)?

Yes

Unknown

Service Name

Full Name of Contact at Service

Contact Email

Contact Telephone

Reason for Referral

Safeguarding & Safety Planning Measures

Have any safeguarding and/or safety planning measures been taken?(Required)

What Safety Measures have been taken so far, or are due to be taken, to mitigate the risk?(Required)

Any other information?

Where did you hear about Savera UK?(Required)

Which directory?(Required)

Who did you hear from?(Required)

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

Please specify(Required)

Helpline 0800 107 0726

Savera UK Referral Form (16+)

Referrer Information

Referrer's Line Manager Details

Risks Identified

Client Details

Client GP Details

Children & Other Family At Risk of Harm

Perpetrator Information

Risk Assessment & Other Agencies

Risk Assessments

Multi-Agency Risk Assessment Conference (MARAC)

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

Other professional involvement

Safeguarding & Safety Planning Measures

Section Break

Our Funders

Menu