Under 16 referral - Savera UK

Savera UK Referral Form (Under 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.

This form is ONLY to be to completed by professionals working with a person under the age of 16 years, who is at risk or may be at risk of ‘honour’-based abuse or/and harmful practices, and requires Savera UK advisory intervention and advice. 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)

Are you the child's key contact?(Required)

If no, where is the child's key contact from?(Required)

If other, please state.(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:

Child/Young Person (YP) Information

Please note: (1) It is NOT Savera UK’s policy to meet independently with child/or young person (YP) under the age of 16 years old (2)We will always meet them with their key worker/professional present if required (3) The advice given will be either verbal or written (4) Savera UK will not take or follow up on actions once advice has been given.

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

What type of accommodation is the client currently living in? (Please select one)(Required)

If "other" please state(Required)

Client Phone Number(Required)

Other form of contact (e.g email)

Gender(Required)

If other, please state(Required)

Ethnicity(Required)

White(Required)

If any other white background, please state(Required)

Mixed/Multiple Ethnic Background(Required)

If any other Mixed/Multiple Ethnic Background, please state(Required)

Asian/Asian British(Required)

If any other Asian background, please state(Required)

Black, African, Caribbean, Black British(Required)

If any other black/African/Caribbean background, please state(Required)

Other Ethnic Group

If 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

School and Key Contact

Is the child or young person in school?(Required)

School Name

School Address

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

Key school contact name

Key school contact email

Key school contact phone

Children & Other Family At Risk of Harm

Are there any other famlily members at risk of harm?(Required)

First Name

Last Name

What is their gender?

If other, please state(Required)

Date of Birth

Are they under the age of 18?

What is their relationship to client?

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)

Date of Birth (Person 2)

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

What is their relationship to client? (Person 2)

If other, please state. (Person 2)

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)

Date of Birth (Person 3)

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

What is their relationship to client? (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)

Date of Birth (Person 4)

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

What is their relationship to client? (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)

Date of Birth (Person 5)

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

What is their relationship to client? (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)(Required)

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.

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)

Untitled

Helpline 0800 107 0726

Savera UK Referral Form (Under 16)

Referrer Information

Referrer's Line Manager Details

Risks Identified

Child/Young Person (YP) Information

School and Key Contact

Children & Other Family At Risk of Harm

Perpetrator Information

Risk Assessment & Other Agencies

Risk Assessments

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

Other professional involvement

Safeguarding & Safety Planning Measures

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