Referral Form for Adult Support Note: Counselling Clients should live within Lancashire Boundaries. We cover Preston, West Lancashire and Chorley for ISVA support.

For completion by Referrer Which Service is required? ISVA / Counselling / Both Delete as appropriate Referred by (name) Agency Contact No(s) Email address

Avoid any delay in process, please complete all fields marked with a *

Client Contact & Personal Information

*Client First Name Title Mr / Mrs/ Ms / Miss/ Dr/ _____

*Client Last Name Known as

*Age: Date of Birth DD/MM/YY Gender Male Female Transgender Male to Female Transgender Female to Male

Street Address Home Tel:

*Town *Mobile Tel No.

*Post Code *Email Address Post *Please tick the *What is the preferred method of communication? Phone call / Voicemail communication method we CAN use Text Phone / Letter / Text / Voicemail / Email Email *Is the Client aware this referral has been made? Yes / No / Unknown

Client Disability Information The following information will help us to ensure that our service is meeting the needs and is accessible to the whole community. Please give us Does your client consider some information themselves to have a Yes / No / Rather not say about this disability? disability *Does your client have any special requirements Please give in order to Yes / No details attend/receive a service from us? 1When completed, please return to:

Trust House Lancashire, PO Box 1355, Preston, PR2 OUE OR [email protected]. We also have a secure email [email protected] Please note you will need to use CJSM email account to use this secure email. 2When completed, please return to:

Trust House Lancashire, PO Box 1355, Preston, PR2 OUE OR [email protected]. We also have a secure email [email protected] Please note you will need to use CJSM email account to use this secure email.

*Safeguarding. Are there any safeguarding issues (if Yes / No / Unknown known)? Name of Social Worker (if known) Contact Info

Incident Information *Has the incident(s) been reported to Please provide details Yes / No / Unknown the Police? Is there a current Police investigation? Yes / No / Unknown *If yes, please provide Crime Number Contact Details (if different to Name of Officer in case front page) Has the offender been arrested? Yes / No / Unknown IS the Offender on Police bail? Yes / No / Unknown Has the Offender been charged Yes / No / Unknown Is the Offender on Court Bail? Yes / No / Unknown Please give details of reason for referral here.

Date of Incident Perpetrator relationship to client? Gender of Perpetrator

Agency Involvement - Please give details of any other agencies involved. (if known)

Agency Contact Contact details

*Does the client have any convictions for either sexual or violent Yes / No / Unknown offences? Please give details here

3When completed, please return to:

Trust House Lancashire, PO Box 1355, Preston, PR2 OUE OR [email protected]. We also have a secure email [email protected] Please note you will need to use CJSM email account to use this secure email. Please call us on 01772 825 288 if you have any queries.

4When completed, please return to:

Trust House Lancashire, PO Box 1355, Preston, PR2 OUE OR [email protected]. We also have a secure email [email protected] Please note you will need to use CJSM email account to use this secure email.