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