Domestic and Sexual Abuse and Violence
Referral Form
Have you assessed your client for risk of domestic or sexual violence?
Assessed as High Risk of Domestic Violence
Experienced Sexual Violence, assessed at Standard,
Medium or Not assessed risk level for DV
Referral to domestic or sexual support services is required
Refer to your local MARAC
If you used the DASH or professional judgement
and assessed your client at high risk of domestic
violence and abuse please refer directly to your
local MARAC. This will result in an automatic
referral to their local IDVA service. You will not
need to complete this form as well.
How to refer to MARAC:
Brighton & Hove:
www.safeinthecity.info/marac
East Sussex:
www.safeineastsussex.org.uk/MARAC
Refer to The Portal
This form is designed to refer all clients who
have experienced sexual violence, or have
been assessed as Standard, Medium or
Unknown risk of domestic violence to
services through The Portal.
Please ensure you complete all relevant
parts of the referral form. Forms where
Sections 1 and 2 are incomplete will be
returned.
Please send the completed form securely as
per the Guidance Notes.
If you’re unsure about risk levels or how to refer please call The Portal 0300 323 9985
Domestic and Sexual Abuse and Violence
Referral Form
1. Referrer
Referrer Name
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Date of referral
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Job Title/Role
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Relationship to client
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Service/Team
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Agency type
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Email Address
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Telephone / ext no.
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2. Key Supporting information
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Is this referral for
Does the client consent to a referral to The Portal?
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Risk Level [If High Risk do not continue with this form. Please refer direct to
your local MARAC – see instructions for details]
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Risk indicator tool used
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Has abuse been reported to the police?
Crime reference number or police serial number
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Police contact name
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Contact number
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Click here to enter a date.
3. Incidents reported to police
For any incidents that were reported to the police
Date
Result
Was the alleged perpetrator arrested?
Choose
Charge date.
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Was the alleged perpetrator cautioned?
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Caution date.
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Was the alleged perpetrator charged?
Choose
Arrest date.
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Send securely as per Guidance Notes
Page 2 of 6
Any questions please contact The Portal 0300 323 9985
4. Client Details
First Name
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Last Name
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Address 1
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Date of Birth
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Address 2
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Telephone no.
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Town
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Email
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Post code
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Client living with perpetrator
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Accompanying
adult (if
applicable)
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Preferred means of safe
contact
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Safe to call
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Safe to leave voicemail
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Safe to text
GP Surgery
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GP Name
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Is the client pregnant?
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How does the client describe their gender identity?
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Is their gender identity the same as they were assigned at birth?
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How does the client describe their sexual orientation?
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How does the client describe their nationality?
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How does the client describe their ethnicity?
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Does the client need translation or an interpreter?
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How does the client describe their religion / faith?
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Does the client identify as having a disability? If so what?
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Does the client need support around use of alcohol or drugs - legal or illicit?
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Does the client identify any mental health support needs?
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Details re the above eg language
Primary support needs sought
from The Portal
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☐
☐
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Emotional support/listening
Advocacy
Information about reporting to the police
Information about domestic violence
Referral to Refuge
Referral to ISVA
Referral to local specialist support
Information about local services
Information about rights and options
Needs not clear
Does the client identify any other support needs, including cultural and religious practice?
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Send securely as per Guidance Notes
Page 3 of 6
Any questions please contact The Portal 0300 323 9985
5. Key details of incident and/or ongoing abuse, including dates of any specific incident.
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6. About the abuse
Details about alleged perpetrator(s) of abuse
Name
Date of Birth
Address
Relation to the Client
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Click here to enter a date.
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Choose an item.
Click here to enter text.
Click here to enter a date.
Click here to enter text.
Choose an item.
Click here to enter text.
Click here to enter a date.
Click here to enter text.
Choose an item.
Type of abuse (tick all
that apply)
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Physical abuse
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Coercive control
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Sexual abuse
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Harassment/stalking
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Rape
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Sexual exploitation/trafficking
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Multi-Assailant rape
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“Honour” based violence
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Sexual assault
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FGM
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Assault by penetration
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Forced Marriage
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Suspected Drug Facilitated Sexual Assault
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Gang-related violence
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Emotional/psychological
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Wants support around past abuse
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Financial
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Non-specific abuse
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Send securely as per Guidance Notes
Any questions please contact The Portal 0300 323 9985
7. Other agencies
Are any of the following aware of or supporting this person?
Agency
Yes / No
Contact name/team and telephone / email
Social Services – Adult
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Social Services – Children
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Health Services
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Mental Health Services
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Police
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AVU / DV case worker
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Victim Support
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Other support person
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Send securely as per Guidance Notes
Page 5 of 6
Any questions please contact The Portal 0300 323 9985
8. Children in the household
Please list all children under 18 whether related to client/and/or perpetrator, individually
Name
Date of Birth
Relationship
with client
Relationship with
alleged perpetrator
Child protection / contact concerns
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Click here to enter
a date.
Choose an item.
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a date.
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a date.
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9. Other dependents (living with client or alleged perpetrator)
Name
Date of Birth
Relationship
with client
Relationship with
alleged perpetrator
Contact details
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Click here to enter
a date.
Choose an item.
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a date.
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a date.
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END OF REFERRAL FORM
Page 6 of 6
Send securely as per Guidance Notes
Any questions please contact The Portal 0300 323 9985