Professional Referral Form

Referral Urgency

Emergency — Same Day Placement Requested Urgent — Within 24 Hours Priority — Within 72 Hours Standard Referral

Client Can Be Contacted Directly

Yes No

Safe to Leave Voicemail

Yes No

Contact Via Referrer Only

Yes No

Current Address / Location

Urgency Reason & Instructions

Current Accommodation Situation

Brief Summary of Circumstances

Why Placement Is Required

Primary Reason for Referral

Abuse Experienced

Non-Molestation / Restraining Order

Yes No

Police Incident Number

Is Perpetrator Aware of Current Location?

Yes No

Known Perpetrator Name(s)

Domestic Abuse Risk Details

Location Restrictions

MARAC Status

MARAC referral made MARAC pending MARAC not known

Agencies Involved

Lead Professional / Key Worker

Agency & Contact Details

Safeguarding Concerns for Adults

Safeguarding Concerns for Children

Has Children?

Yes No

Children Living With Client?

Yes No

Children Visiting?

Yes No

Mother & Child Accommodation Required?

Yes No

Women-Only Shared Accommodation Required?

Yes No

School / Nursery Considerations

Contact Arrangements Need Consideration

GP Registered?

Yes No

Physical Health Conditions

Allergies or Medical Alerts

Medication Requirements

Mobility / Disability Needs

Accessible Room Required?

Yes No

Ground Floor Required?

Yes No

Medication Storage Needed?

Yes No

Regular Medical Appointments?

Yes No

Mental Health Concerns

Current Mental Health Worker / Team

Crisis Plan in Place?

Yes No

Currently Under CMHT?

Yes No

Mental Health Risks, Triggers & Support Required

Substance Use and Recovery Needs

Substance Misuse Service Involved?

Yes No

Testing or Treatment Requirements

Substance Use Summary & Impact on Shared Living

Probation Officer Name

Probation Contact Details

Licence Conditions / Restrictions

Offending History

Current Benefit Status

Requires Benefits Support?

Yes No

ID Documents Available?

Yes No

Bank Account Active?

Yes No

Debt Concerns

Yes No

Local Authority Homeless Application Status

Financial Issues or Documents Required

Support Needs

Recommended Support Level

Low Medium High

Preferred Support Style

Frequency of Support Required

Expected Length of Stay

Known Engagement Issues

Support Needs Summary & Outcomes Sought

En-Suite Required?

Yes No

Ground Floor Required?

Yes No

Client Can Use Shared Kitchen?

Yes No

Client Suitable for Shared Lounge?

Yes No

No Visitor Access Recommended?

Yes No

Pets / Assistance Animal

Other Special Requirements

Equality & Communication Needs

Cultural Considerations

Dietary Requirements

Shared Accommodation Suitability

Can live safely in shared accommodation Can follow house rules No known risk to other residents Not suitable for shared housing Can manage basic self-care Can engage with support May need increased monitoring Further risk assessment required

Further Equality or Communication Needs

Behavioural Concerns, Triggers or Previous Placement Breakdowns

Photo ID & Proof of Benefits

Upload Supporting Documents

Consent

I confirm the information provided is accurate

Safe Haven

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