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)

Reach Out is a consent-based service. Please only complete this referral where the victim/survivor has consented to the referral. If it is not safe or appropriate for you to seek consent, please contact Reach Out to discuss the referral before submitting this form.

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).

Consent for referral

! Warning Reach Out is a consent-based service. Please only complete this referral where the victim/survivor has consented. Exceptions apply where there is an agreed arrangement with Reach Out to accept referrals without prior consent. In these cases, Reach Out will contact the victim/survivor to discuss support and obtain their consent. If this cannot be obtained, the referral cannot be accepted.

Has the victim/survivor consented to a referral to a domestic abuse service (Reach Out or one of our partner independent domestic abuse advocacy services)?(Required)

Yes

Reason for not obtaining consent(Required)

Is the Perpetrator aware of this referral?

Yes

Professional’s details

First name of worker completing referral(Required)

Last name of worker completing referral(Required)

Position/Title(Required)

Agency/Organisation(Required)

Professional's contact details

Telephone number(Required)

Email(Required)

Victim/survivor's details

First name(Required)

Last name(Required)

Date of birth

Day

Month

Year

Victim/survivor's details

Address

Enter a postcode or street to find and select an address in Redbridge.

Find addressSelected address

Address not found?

Only use this option if the address is in Redbridge but does not appear in the address search.

I cannot find the Redbridge address

Address

Street Address Address Line 2 City County Postcode

Email address

Victim/survivor's details

Mobile number

Safest times to contact the victim/survivor

Victim/survivor's details

Interpreter required?

Yes

Preferred language

Victim/survivor's details

Ethnicity

Victim/survivor's 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 gender

Female

Male

Non-binary

Transgender

Other

Prefer not to say

Unknown

Victim/survivor's sexuality

Heterosexual/straight

Gay or lesbian

Bisexual

Pansexual

Other

Prefer not to say

Unknown

Victim/survivor's religion

No religion

Buddhist

Christian (including Church of England, Catholic, Protestant and all other Christian denominations)

Hindu

Jewish

Muslim

Sikh

Other

Prefer not to say

Unknown

Any alcohol or substance misuse by the victim/survivor?

Yes

Please give details of alcohol or substance misuse?

What is the current relationship between victim/survivor and perpetrator?

In relationship

Ex-partner

Separated

Familial (for example, child-to-parent)

Unknown

Other

Please state relationship

Children’s details

Do they have children under the age of 18?

Yes

Please provide children's details

Child's first name	Child's last name	Date of birth	Address (If different from parents)	Actions

There are no Entries.

Maximum number of entries reached.

Do 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 Open Up Programme (opens in new window).

Yes

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

Please provide perpetrator’s details

First name	Last name	Date of birth	Email address	Actions

There are no Entries.

Maximum number of entries reached.

Perpetrator’s details

First name

Last name

Date of birth

Day

Month

Year

Perpetrator’s details

Full address

Street Address Address Line 2 City County Postcode

Mobile number

Email address

Perpetrator’s details

Interpreter required?

Yes

Preferred language

Ethnicity

Does the perpetrator have any 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 gender

Female

Male

Non-binary

Transgender

Other

Prefer not to say

Unknown

Perpetrator’s sexuality

Heterosexual/ straight

Gay or lesbian

Bisexual

Pansexual

Other

Prefer not to say

Unknown

Any alcohol or substance misuse by the perpetrator?

Yes

Please give details of alcohol or substance misuse?

Are there other household members?

Yes

Unknown

Please provide details of other household members

First name	Last name	Date of birth	Actions

There are no Entries.

Maximum number of entries reached.

Reason for referral

Reason 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).

Other professionals

Any other professionals involved?

Worker

Agency

Phone number

Involved with whom?

Risk assessment

Have you already completed the DASH Risk Identification Checklist?

Yes

Please upload the DASH Risk Identification Checklist

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