Positive Relationships Gloucestershire (PRG) Referral Form

Referrer details

Position

Organisation

Agreement

Please confirm that agreement has been given by the perpetrator and/or victim for this referral and that they agree for you to share their information on a need-to-know basis.

Perpetrator agreement
YesNo

Victim agreement
YesNo

Please note: Agreement must be confirmed before the referral can be accepted and processed.

Perpetrator

Address

Relationship to victim

Communication requirements
InterpreterDeaf/BSLEasy ReadLarge PrintOtherNone/Not known

Communication requirement details

Any known risks or hazards the service should be aware of?

Primary person affected directly by domestic abuse

Address

Communication requirements
InterpreterDeaf/BSLEasy ReadLarge PrintOtherNone/Not known

Communication requirement details

Children’s details

Child 1

Name
Sex Please selectFemaleMalePrefer to self-describeNot known
Date of birth
Nationality
Relationship Please selectChild to bothChild to victimChild to perpetrator

Child 2

Name
Sex Please selectFemaleMalePrefer to self-describeNot known
Date of birth
Nationality
Relationship Please selectChild to bothChild to victimChild to perpetrator

Child 3

Name
Sex Please selectFemaleMalePrefer to self-describeNot known
Date of birth
Nationality
Relationship Please selectChild to bothChild to victimChild to perpetrator

Child 4

Name
Sex Please selectFemaleMalePrefer to self-describeNot known
Date of birth
Nationality
Relationship Please selectChild to bothChild to victimChild to perpetrator

Child 5

Name
Sex Please selectFemaleMalePrefer to self-describeNot known
Date of birth
Nationality
Relationship Please selectChild to bothChild to victimChild to perpetrator

Current Children’s Services involvement
Please selectNo current involvementEarly HelpChild in NeedChild ProtectionLooked After ChildOtherNot known

If other, please provide details

Reason for referral

Please provide full details of the reason for referral, including relevant history, identified risks, current concerns and desired outcomes

Additional person affected by domestic abuse 1

First name
Surname
Date of birth
Age
Address
Contact number(s)
Email
Gender Please selectFemaleMaleNon-binaryPrefer to self-describePrefer not to sayNot known
Sexual orientation Please selectBisexualGay manGay woman/LesbianHeterosexual/StraightPansexualPrefer to self-describePrefer not to sayNot known
Nationality
Ethnicity
Disability Please selectYesNoPrefer not to sayNot known
Substance use Please selectYesNoNot known
Mental health needs Please selectYesNoNot known
Religion or belief
Marital status
Parental status Please selectParentExpectant parentNot a parentNot known
Pregnant Please selectYesNoNot applicableNot known
Repeat victim Please selectYesNoNot known
Communication requirements
InterpreterDeaf/BSLEasy ReadLarge PrintOtherNone/Not known
Communication requirement details

Additional person affected by domestic abuse 2

First name
Surname
Date of birth
Age
Address
Contact number(s)
Email
Gender Please selectFemaleMaleNon-binaryPrefer to self-describePrefer not to sayNot known
Sexual orientation Please selectBisexualGay manGay woman/LesbianHeterosexual/StraightPansexualPrefer to self-describePrefer not to sayNot known
Nationality
Ethnicity
Disability Please selectYesNoPrefer not to sayNot known
Substance use Please selectYesNoNot known
Mental health needs Please selectYesNoNot known
Religion or belief
Marital status
Parental status Please selectParentExpectant parentNot a parentNot known
Pregnant Please selectYesNoNot applicableNot known
Repeat victim Please selectYesNoNot known
Communication requirements
InterpreterDeaf/BSLEasy ReadLarge PrintOtherNone/Not known
Communication requirement details

I confirm that the information provided is accurate to the best of my knowledge and that the required agreement to share information has been obtained.