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]