<p> Supported Volunteering Service Referral Form</p><p>This service helps people with additional needs into voluntary work. We endeavour to find the right placement for your client. We will give feedback on the outcome of your clients contact with the Supported Volunteering Project. </p><p>Clients name:</p><p>Clients Address:</p><p>Clients e-mail:</p><p>Phone Number:</p><p>Date of Birth:</p><p>Name of Referrer:</p><p>Name of Referrers Agency:</p><p>Relationship to Client:</p><p>Referrers Address:</p><p>Referrers E mail:</p><p>Referrers Phone number:</p><p>Once completed this form must be returned to [email protected] Please indicate any relevant volunteering or work experience your client has undertaken:</p><p>Do you have any ideas about what your client would like to do or any particular interests? Please outline:</p><p>Why do you feel volunteering is an appropriate next step for your client? </p><p>Why does your client want to participate in the Supported Volunteering Project RISK ASSESSMENT FOR VOLUNTEERING</p><p>Does your client consider themselves to have a disability according to the terms given in the DDA?</p><p>Yes No Prefer not to say</p><p>If you have answered yes, please indicate the type of impairment which applies to you. If your experience more than one type of impairment, please tick all the types that apply. If your disability does not fit any of these types, please mark Other and specify.</p><p>Physical/mobility impairment, such as a difficulty using your arms or mobility issues which require you to use a wheelchair or crutches Visual impairment, such as being blind or having a serious visual impairment Hearing impairment, such as being deaf or having a serious hearing impairment Mental health condition, such as depression or schizophrenia Learning disability/difficulty, such as Down’s syndrome or dyslexia or a cognitive impairment such as autistic spectrum disorder Long-standing illness or health condition, such as cancer, HIV, diabetes, chronic heart disease or epilepsy Other (Please specify below)</p><p>KNOWN RISK BEHAVIOUR Violence to Others Used Weapons Threats/Threatening Behaviour Arson Sexual assault Threats/violence to children Self-Harm Alcohol/Drug Abuse Significant damage to property</p><p>If any of the above have been ticked, please give brief details below: Have there been any known incidents of serious risk behaviour to self or others? </p><p>If so, please give brief details here, including dates:</p><p>Are there any other risk factors that may affect your client when volunteering?</p><p>Do you have any unspent criminal convictions? </p><p>Yes No </p><p>Please note that many volunteering opportunities require a DBS check.</p><p>I confirm that my client has read through the details given on this form and has given their permission to share information about them, that is relevant to volunteering, to the Supported Volunteering Project at Cambridge Council for Voluntary Sector.</p><p>Name of Referrer: Date: Signature of Referrer</p>