Referral Form Name * First Name Last Name Date * Date of birth MM DD YYYY Phone Number Please enter a phone number that it is safe for us to call: When is is safe to call? * Can a message be left on this number? * Yes - voicemails can be left on this number. No - please do not leave voicemails on this number. Email Address * Address Address - please include postcode. Is the client living with the abusive partner?/family member? * Yes No Which Freedom Session would they like to attend? Would the client prefer face to face or virtual group? * Face to face group Virtual Group Do you have an allocated social worker? * Yes No Details of Family Members in Household * Please provide their full name, relationship to client, date of birth and gender. RIC Score & date of assessment: (if completed) Referrer’s Details * (Who told them/you about the Freedom Programme?) First Name Last Name Referring Agency * Please include contact details including phone number: Referrers Contact Details (please include email and phone) * Referrers Contact Details (please include email and phone) What is your Ethnicity? White - British White - Irish White - Other Mixed - White & Black Carribean Mixed - White & Black African Mixed - White & Asian Mixed - Other Black or Black British - Carribean Black or Black British - African Black or Black British - Other Asian or Asian British - Indian Asian or Asian British - Pakistani Asian or Asian British - Bangladeshi Asian or Asian British - Other Chinese Other Ethnic Group Name of alleged perpetrator: * First Name Last Name Date of birth of alleged perpetrator If known MM DD YYYY Address of alleged perpetrator (if known) Relationship to you: * Would you recognise the early warnings of a potentially abusive relationship? Yes No Has client consented to this referral? Yes - full consent provided No consent given Thank you for submitting a Freedom Programme Referral Form. This has been automatically sent to our team, who will process it onto the waiting list. We will contact the client directly as soon as a space becomes available on the programme.
