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Savera UK

Savera UK

Savera UK

Helpline 0800 107 0726

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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, 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.

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.
Date of referral to Savera UK

Referrer Information

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.
Date of Birth(Required)
Child/YP Address(Required)
Is an interpreter required?
Are they currently practicing it?

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)?

School & Key Contact

School Address(Required)

Child/YP Environment & Consent

Other Family At Risk of Harm

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

Safeguarding & Safety Planning Measures

Has any safeguarding or safety planning been completed?(Required)
Is any action pending?(Required)
(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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