Glossop Women S Aid Admission Policy
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Crossroads Derbyshire Referral form for WAGs Project
Date of referral:
Referral for: WAG-S Group Work WAG-S One to One Both
Name:
Date of Birth:
(If under 16 is parent aware of referral?)
Next of Kin Name and Contact Details
Address & Postcode:
Safe Contact Number(s)
(Can we ring and/or text this number? Is there a best time to contact? )
School/College/University/ Employment/Training
Does the young woman have any disabilities/educational needs/special requirements?
Does the young woman have any …………………………………………………………………… children? If yes please detail names …………………………………………………………………… and DOB. …………………………………………………………………… Child Protection Issues?
Reason(s) for referral Presenting issues/concerns or at risk of:-
Domestic Abuse Relationship concerns
Please return this form to Melissa Morten, Crossroads Derbyshire, P.O Box 22, Glossop, Derbyshire, SK13 8AE or email to [email protected]
Self-harm Mental Health
Low confidence Vulnerability to abuse
Drug and Alcohol abuse Child Sexual Exploitation
Other (please specify) ………………………………………………………… Information about the incident/reason for referral: (Please detail as much information as reasonably possible)
RIC completed? Yes - Score :
Is the service user known to pose any risk to staff?
If yes, please detail.
Other Agencies involved?
(Police, Children’s Services, Drug services, MAT team) Perpetrator details:(if relevant) Name: Address: DOB:
Bail Conditions or Charges? Referring Agency details: Name: Address: Contact Number: How did you hear about the WAG-S Project?
Please return this form to Melissa Morten, Crossroads Derbyshire, P.O Box 22, Glossop, Derbyshire, SK13 8AE or email to [email protected]
Equalities Data
To help us monitor how our service is being used please complete this monitoring form for each referral. Please circle and specify
AGE GROUP
13 - 15 16 - 18 19 - 24
ETHNIC ORIGIN
Asian or Asian British White
Indian British
Pakistani Irish
Bangladeshi Other European
Any other Asian Background Other Non European
Black or Black British Dual Heritage
Caribbean White & Black Caribbean
African White and Black African
Other Black background White and Asian
Other Dual Heritage (Please Specify) ......
Chinese or other ethnic groups
Chinese Other (please specify)…………………………………....
Please return this form to Melissa Morten, Crossroads Derbyshire, P.O Box 22, Glossop, Derbyshire, SK13 8AE or email to [email protected]
SEXUALITY
Heterosexual Lesbian
Bi-sexual Not Disclosed
EMPLOYMENT STATUS
Receiving ESA Receiving Income Support Receiving JSA Receiving DLA Part Time Work Full time Work Other ………………………………….. Student Universal Credit
Please return this form to Melissa Morten, Crossroads Derbyshire, P.O Box 22, Glossop, Derbyshire, SK13 8AE or email to [email protected]