Forms home Redbridge Reach Out Service Referral The Reach Out service assesses risk, carries out safety planning, and links those who have been affected by domestic abuse to practical and emotional support. Abusive behaviour is considered domestic abuse if both individuals are over the age of 16 and are personally connected (e.g. in a relationship, separated, relatives). For a full description of what personally connected means please visit the legislation.gov.uk website (opens in a new window)This referral form has been designed for professionals. If it is safe to do so, please advise the individual that you are making a referral on their behalf before doing so.The Reach Out service operates from Monday – Friday (9am-5pm). If someone would like to seek help outside of these hours, please encourage them to call the 24-hour national domestic abuse helpline on 0808 2000 247. For access to social care out of hours, you can contact the Adult Emergency Duty Team on 0208 554 5000 or Children’s Emergency Duty Team on 0208 708 5879. In the event of an emergency, please call the police on 999.If there are children involved, please note that this referral will be passed onto Redbridge’s Multi Agency Safeguarding Hub (MASH).Professional’s detailsName of worker completing referral(Required) Position/Title(Required) Agency/Organisation(Required) Professional's contact detailsTelephone number(Required) Email address(Required) Victim/survivor's detailsLast name(Required) First name(Required) Date of birth Victim/survivor's detailsFull address Street Address Address Line 2 City AberdeenshireAngus/ForfarshireArgyllshireAyrshireBanffshireBedfordshireBerkshireBerwickshireBlaenau GwentBridgendBuckinghamshireButeshireCaerphillyCaithnessCambridgeshireCardiffCarmarthenshireCeredigionCheshireClackmannanshireConwyCornwallCromartyshireCumberlandDenbighshireDerbyshireDevonDorsetDumfriesshireDunbartonshire/DumbartonshireDurhamEast Lothian/HaddingtonshireEssexFifeFlintshireGloucestershireGwyneddHampshireHerefordshireHertfordshireHuntingdonshireInverness-shireIsle of AngleseyKentKincardineshireKinross-shireKirkcudbrightshireLanarkshireLancashireLeicestershireLincolnshireLondonMerthyr TydfilMiddlesexMidlothian/EdinburghshireMonmouthshireMorayshireNairnshireNeath Port TalbotNewportNorfolkNorthamptonshireNorthumberlandNottinghamshireOrkneyOxfordshirePeeblesshirePembrokeshirePerthshirePowysRenfrewshireRhondda Cynon TaffRoss-shireRoxburghshireRutlandSelkirkshireShetlandShropshireSomersetStaffordshireStirlingshireSuffolkSurreySussexSutherlandSwanseaTorfaenVale of GlamorganWarwickshireWest Lothian/LinlithgowshireWestmorlandWigtownshireWiltshireWorcestershireWrexhamYorkshire County Postcode Email address Victim/survivor's detailsMobile number Safest time/s to contact the victim/survivor Victim/survivor's detailsInterpreter required? Yes No First language Victim/survivor's detailsEthnicityPlease selectABAN- Bangladeshi (Asian//Asian British)AIND- Indian (Asian/Asian British)AOTH- Any Other Asian Background (Asian/Asian British)APKN- Pakistani (Asian/Asian British)BAFR- African (Black/Black British)BCRB- Caribbean (Black/Black British)BOTH- Any Other Black Background (Black/Black British)CHNE- ChineseMOTH- Any Other Mixed Background (Mixed)MWAS- White & Asian (Mixed)MWBA- White & Black African (Mixed)MWBC- White & Black Caribbean (Mixed)NOBT- Information Not Yet ObtainedOOTH- Any Other Ethnic GroupREFU- RefusedWBRI- White British (White)WIRI- White Irish (White)WIRT- Traveller of Irish Heritage (White)WOTH- Any Other White Background (White)WROM - Gypsy/Roma (White)Disabilities (including Mental Health) Physical Sensory Mental health condition Learning disabilities No disabilities Unknown Please provide more detail regarding the disability including any support needs we need to take into consideration. Victim/survivor's detailsGenderPlease selectMaleFemaleNon-BinaryTransgenderOtherPrefer not to sayUnknownSexualityPlease selectHeterosexual/ straightGay or lesbianBisexualPansexualOtherPrefer not to sayUnknown Victim/survivor's detailsAny alcohol or substance misuse? Yes No Please give details of alcohol or substance misuse?What is the current relationship between victim/survivor and perpetrator?Please selectIn relationshipEx-partnerSeparatedFamilial (e.g.: child-to-parent)UnknownOtherPlease state relationship Children’s details Do they have children under the age of 18? Yes No Please provide children's details Child's full name Date of birth Address (If different from parents) Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Perpetrator’s detailsDo you know the perpetrator/s details(Required)Once we have spoken to the victim/ survivor, we will also contact the perpetrator of the abuse if it is safe to do so. If they wish to address their abusive behaviours, we can refer them to our Spotlight Programme. Yes No Are there multiple perpetrators?(Required)Please let us know if the individual is at risk of abuse from multiple perpetrators; for example, they might be at risk from multiple members of their family or their in-laws Yes No Please provide perpetrator’s details Last name First name Date of birth Email address Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Perpetrator’s detailsLast name First name Date of birth Perpetrator’s detailsFull address Street Address Address Line 2 City AberdeenshireAngus/ForfarshireArgyllshireAyrshireBanffshireBedfordshireBerkshireBerwickshireBlaenau GwentBridgendBuckinghamshireButeshireCaerphillyCaithnessCambridgeshireCardiffCarmarthenshireCeredigionCheshireClackmannanshireConwyCornwallCromartyshireCumberlandDenbighshireDerbyshireDevonDorsetDumfriesshireDunbartonshire/DumbartonshireDurhamEast Lothian/HaddingtonshireEssexFifeFlintshireGloucestershireGwyneddHampshireHerefordshireHertfordshireHuntingdonshireInverness-shireIsle of AngleseyKentKincardineshireKinross-shireKirkcudbrightshireLanarkshireLancashireLeicestershireLincolnshireLondonMerthyr TydfilMiddlesexMidlothian/EdinburghshireMonmouthshireMorayshireNairnshireNeath Port TalbotNewportNorfolkNorthamptonshireNorthumberlandNottinghamshireOrkneyOxfordshirePeeblesshirePembrokeshirePerthshirePowysRenfrewshireRhondda Cynon TaffRoss-shireRoxburghshireRutlandSelkirkshireShetlandShropshireSomersetStaffordshireStirlingshireSuffolkSurreySussexSutherlandSwanseaTorfaenVale of GlamorganWarwickshireWest Lothian/LinlithgowshireWestmorlandWigtownshireWiltshireWorcestershireWrexhamYorkshire County Postcode Mobile number Email address Perpetrator’s detailsInterpreter required Yes No First language Perpetrator’s detailsEthnicityPlease selectABAN- Bangladeshi (Asian//Asian British)AIND- Indian (Asian/Asian British)AOTH- Any Other Asian Background (Asian/Asian British)APKN- Pakistani (Asian/Asian British)BAFR- African (Black/Black British)BCRB- Caribbean (Black/Black British)BOTH- Any Other Black Background (Black/Black British)CHNE- ChineseMOTH- Any Other Mixed Background (Mixed)MWAS- White & Asian (Mixed)MWBA- White & Black African (Mixed)MWBC- White & Black Caribbean (Mixed)NOBT- Information Not Yet ObtainedOOTH- Any Other Ethnic GroupREFU- RefusedWBRI- White British (White)WIRI- White Irish (White)WIRT- Traveller of Irish Heritage (White)WOTH- Any Other White Background (White)WROM - Gypsy/Roma (White)Disabilities (including Mental Health) Physical Sensory Mental health condition Learning disabilities No disabilities Unknown Please provide more detail regarding the disability including any support needs we need to take into consideration. Perpetrator’s detailsGenderPlease selectMaleFemaleNon-BinaryTransgenderOtherPrefer not to sayUnknownSexualityPlease selectHeterosexual/ straightGay or lesbianBisexualPansexualOtherPrefer not to sayUnknownAny alcohol or substance misuse? Yes No Please give details of alcohol or substance misuse? Other household membersAre there other household members? Yes No Unknown Please provide details of other household members Full name Date of birth Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Reason for referralReason for referring(Required)Please state any present/historical concerns and describe the perpetrator’s pattern of behaviour (such as physical abuse, sexual abuse, financial abuse, psychological abuse & coercive control). Reason for referralIs the victim/survivor aware of this referral?(Required) Yes No Is the Perpetrator aware of this referral? Yes No Has the victim/survivor consented to this referral being made?If no, we will contact them to request their consent Yes No Other ProfessionalsAny other professionals involved?WorkerAgencyPhone numberInvolved with whom? Add Remove Risk assessmentHave you already completed the DASH Risk Identification Checklist? Yes No Please upload the DASH Risk Identification ChecklistAccepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 10 MB.
