Details of Referral

Please enter details as required below. Note: this information will be collected and stored by Victim Support. Please refer to the VS privacy policy via www.new-era.uk for more details of how your data will protected.

Would you like the support for yourself or somebody else?

Myself

Individual - on behalf of somebody else

Police - on behalf of somebody else

Other Agency - on behalf of somebody else

Specialist Service

I require Support service for a

Person aged 16+ Person aged 15 and under

Do you require dedicated service for:

Female Male LGBT+ (Lesbian, Gay, Bisexual, Transgender) BAME (Black And Minority Ethnic)

Female

In case of an emergency, we encourage you to call 999 or contact the Police

Immediate Risk Assessment

Are you frightened and at immediate risk?

Have you recently separated or is there one imagined or planned?

Has there been any recent aggression, control or violence?

Has the alleged perpetrator got a history of abuse with you or any other partner?

Is there any stalking or harassment occurring?

Contact Details

First name

Surname

Any Other name used

Date of Birth

House number or Flat number

Street

Town

County

Postcode

Is it Safe to send post to this address?

Yes

No

Email Address

Is it Safe to email?

Yes

No

Primary Telephone

Please select which number it is

Personal Mobile

Work Mobile

Home landline

Another Safe Number

Is it Safe to text on this number?

Yes

No

Is it Safe to leave message on this number?

Yes

No

Secondary Telephone

Please select which number it is

Personal Mobile

Work Mobile

Home landline

Another Safe Number

Is it Safe to text on this number?

Yes

No

N/A

Is it Safe to leave message on this number?

Yes

No

N/A

What is your immigration status?(BAME)

Needs Assessment

Please write what other abuse or concern you have

Can you provide a brief history of your circumstances?

Would you prefer to be supported by a male support worker? (Male)

Equality, Diversity & Inclusion

Identified Gender

If you choose other, please enter your Gender

Sexual Orientation

If you choose other, please enter your Sexual Orientation

Ethnicity

If you choose other, please enter your Ethnicity

Religion

If you choose other, please enter your Religion

Translator required

Yes No Unknown

Language Spoken

Do you have any Disability?

Yes

No

Please enter your Disability

Are you Pregnant?

Yes

No

Do you have Children?

Yes

No

Would you like to refer your children for support?

Yes No

Details of Children

Please enter the details of your child or children.
Name	DOB	Relationship to child	Do you have Parental Responsibility	Any child contact arrangements/orders in place or pending through family court	Are CAFCASS involved

On Behalf of - Person aged 16+

Please enter your details below

First name

Surname

Relationship to person being referred

If Other, please enter the type of Relationship

Your Telephone number

Your Email Address

Does the person being referred know about this referral to New Era?

Yes

Have they consented to their information being passed to New Era?

Yes

Contact Details for the Victim

Please enter the details of the person being referred

First name

Surname

Any Other name used

Date of Birth

House number or Flat number

Street

Town

County

Postcode

Is it Safe to send post to this address?

Yes

No

Email Address

Is it Safe to email?

Yes

No

Primary Telephone

Is it Safe to text on this number?

Yes

No

Is it Safe to leave message on this number?

Yes

No

Can you describe what you are requesting support for. Please give details of the circumstances and history of the domestic abuse?

Is there any risk information you feel we ought to be aware of?

If Other, please enter the Type of Risk

Identified Gender

If you choose other, please enter your Gender

Sexual Orientation

If you choose other, please enter their Sexual Orientation

Ethnicity

If you choose other, please enter their Ethnicity

Religion

If you choose other, please enter their Religion

Translator required

Yes No Unknown

Language Spoken

Do they have any Disability?

Yes

No

Please enter their Disability

Are they Pregnant?

Yes

No

Do they have Children?

Yes

No

Would you like to refer their children for support?

Yes No

Details of Children

Please enter the details of their child or children.
Name	DOB	Relationship to child	Do you have Parental Responsibility	Any child contact arrangements/orders in place or pending through family court	Are CAFCASS involved

AGENCY Referral - Person aged 16+ Referral form (Police)

In case of an emergency, we encourage you to call 999 or contact the Police

Enter your details

Your name

Your Email Address

Please confirm the victim has been informed of the referral to New Era and given the opportunity to opt out

Yes

No

Contact Details for the Victim

Please enter the details of the person being referred

First name

Surname

Any Other name used

Date of Birth

House number or Flat number

Street

Town

County

Postcode

Is it Safe to send post to this address?

Yes

No

Unknown

Please confirm safe telephone number for the victim

Is it Safe to text on this number?

Yes

No

Is it Safe to leave voice message on this number?

Yes

No

Identified Gender

If you choose other, please enter their Gender

Sexual Orientation

If you choose other, please enter their Sexual Orientation

Ethnicity

If you choose other, please enter their Ethnicity

Religion

If you choose other, please enter their Religion

Translator required

Yes No Unknown

Language Spoken

Do they have any Disability?

Yes

No

Unknown

Please enter their Disability

Are they Pregnant?

Yes

No

Unknown

Do they have Children?

Yes

No

Unknown

Would you like to refer their children for support?

Yes No

Details of Children

Please enter the details of their child or children.
Name	DOB	Relationship to child	Do you have Parental Responsibility	Any child contact arrangements/orders in place or pending through family court	Are CAFCASS involved

Crime/Incident reference number

Please ensure you attach the PPN, MPIR or other relevant documents at the end of this referral form

Brief History and Notes for referral

AGENCY Referral - Person aged 16+ Referral form

In case of an emergency, we encourage you to call 999 or contact the Police

Enter your details

Your name

Name of your Agency or Organisation

Your Job Title

Email Address

Telephone number

Does the person being referred know about this referral and has consented to their information being passed to New Era?

Yes

Contact Details for the Victim

Please enter the details of the person being referred

First name

Surname

Any Other name used

Date of Birth

House number or Flat number

Street

Town

County

Postcode

Is it Safe to send post to this address?

Yes

No

Email Address

Is it Safe to email?

Yes

No

Please confirm safe telephone number for the victim

Is it Safe to text on this number?

Yes

No

Is it Safe to leave voice message on this number?

Yes

No

Please write what other abuse or concern you have

Please give details of the circumstances and history of the domestic abuse you have identified?

Can you provide a brief history of your services involvement to date?

Identified Gender

If you choose other, please enter their Gender

Sexual Orientation

If you choose other, please enter their Sexual Orientation

Ethnicity

If you choose other, please enter their Ethnicity

Religion

If you choose other, please enter their Religion

Translator required

Yes No Unknown

Language Spoken

Do they have any Disability?

Yes

No

Unknown

Please enter their Disability

Are they Pregnant?

Yes

No

Unknown

Do they have Children?

Yes

No

Unknown

Would you like to refer their children for support?

Yes No Unknown

Details of Children

Please enter the details of their child or children.
Name	DOB	Relationship to child	Do you have Parental Responsibility	Any child contact arrangements/orders in place or pending through family court	Are CAFCASS involved

Are you aware of any of the following in place:

Police involvement

Legal Orders

If you choose other, please enter the Legal order

Safeguarding processes

If you choose other, please enter the Safeguarding process

Is there any risk information you feel we ought to be aware of?

If you choose other, please enter the Risks involved

Agency Referral - Person under age 15

In case of an emergency, we encourage you to call 999 or contact the Police

What are you requesting support for

Note: We cannot contact young people directly and need to arrange our service via a safe contact in the first instance, this is usually someone with Parental Responsibility. Please provide a named safe contact to call on your behalf to arrange support

Safe Contact details

First name

Surname

Current Address of the Safe contact person

Can you provide full address of the Safe contact person?

Relationship to the young person

Telephone number of the safe contact

Have you obtained parental consent to refer the young person to New Era

Yes

Referring Agency

Please enter the agency you represent

Police

Social Care

Other Local Authority

Other DA service

Name of Educational Establishment

Other

If choose Other, please enter the Type of Agency

Choose the agency

Choose the DA service

If choose Other, please enter the DA service

Please enter the Name of Educational Establishment

AGENCY Referral - Person under 15 Referral form (Police)

In case of an emergency, we encourage you to call 999 or contact the Police

Enter your details

Your name

Your Job Title

Your Telephone number

Your Email Address

Please confirm someone with parental responsibility has consented to the referral to New Era

Yes

No

Note: We cannot contact young people directly and need to arrange our service via a safe contact in the first instance, this is usually someone with Parental Responsibility. Please provide a named safe contact to call on your behalf to arrange support

Contact Details for the Victim

Please enter the details of the person being referred

First name

Surname

Any Other name used

Date of Birth

House number or Flat number

Street

Town

County

Postcode

Is it Safe to send post to this address?

Yes

No

School attended

Crime/Incident reference number

Please ensure you attach the PPN, MPIR or other relevant documents at the end of this referral form

Any Additional Notes

Alleged Perpetrator Details

First name

Surname

Current Address

Can you provide full address of the Perpetrator?

Referral's Relationship to alleged perpetrator

Identified Gender

If you choose other, please enter their Gender

Immediate Safety Needs

Have any incidents been reported to the police?

Further details

Are there any protection orders in place?

If yes, please choose what type of protection

If Other, please enter the type of Protection

Are there any other agencies involved/supporting?

Is Yes, please enter the name

Is there a legal representative involved?

Is Yes, please enter the name

Is there a need for safe accommodation?

If Yes, please call us on 0300 303 3778

Data use/collection

New Era is a confidential service but on occasion we may be asked to share your information with other agencies. Do you consent to us sharing your details with any of the following

(Tick all that apply):

Staffordshire police

Staffordshire Multi Agency Safeguarding Hub

Children & Families Social Care

Adult Social Care

Housing Team

Educational Establishment

Unknown

There may be occasions we need to share your details without your explicit consent for safeguarding and/or legal purposes. Please refer to our Privacy Notice on www.victimsupport.org.uk

Please tick here to confirm you are happy with our privacy notice

I accept

How did you hear of New Era

Thank you for referral

We aim to respond within 2 working days

Upload your support files

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Details of Referral

Specialist Service

Female

In case of an emergency, we encourage you to call 999 or contact the Police

Immediate Risk Assessment

Contact Details

Needs Assessment

Equality, Diversity & Inclusion

Details of Children

On Behalf of - Person aged 16+

Please note we cannot make contact or hold any information without consent of the ‘data subject’. Please seek consent and re-refer using this form or contact us on 0300 303 3778

Contact Details for the Victim

Details of Children

AGENCY Referral - Person aged 16+ Referral form (Police)

In case of an emergency, we encourage you to call 999 or contact the Police

Enter your details

Please note we cannot make contact or hold any information without consent of the ‘data subject’. Please seek consent and re-refer using this form or contact us on 0300 303 3778

Contact Details for the Victim

Details of Children

AGENCY Referral - Person aged 16+ Referral form

In case of an emergency, we encourage you to call 999 or contact the Police

Enter your details

Please note we cannot make contact or hold any information without consent of the ‘data subject’. Please seek consent and re-refer using this form or contact us on 0300 303 3778

Contact Details for the Victim

Details of Children

Are you aware of any of the following in place:

Person under age 15

In case of an emergency, we encourage you to call 999 or contact the Police

Safe Contact details

Contact Details

Needs Assessment

Equality, Diversity & Inclusion

On Behalf of - Person under age 15

In case of an emergency, we encourage you to call 999 or contact the Police

Enter your details

Please note we cannot make contact or hold any information without consent of the ‘data subject’. Please seek consent and re-refer using this form or contact us on 0300 3030 1977

Note: We cannot contact young people directly and need to arrange our service via a safe contact in the first instance, this is usually someone with Parental Responsibility. Please provide a named safe contact to call on your behalf to arrange support

Safe Contact details

Contact Details of the Young person

Agency Referral - Person under age 15

In case of an emergency, we encourage you to call 999 or contact the Police

Note: We cannot contact young people directly and need to arrange our service via a safe contact in the first instance, this is usually someone with Parental Responsibility. Please provide a named safe contact to call on your behalf to arrange support

Safe Contact details

Referring Agency

AGENCY Referral - Person under 15 Referral form (Police)

In case of an emergency, we encourage you to call 999 or contact the Police

Enter your details

Note: We cannot contact young people directly and need to arrange our service via a safe contact in the first instance, this is usually someone with Parental Responsibility. Please provide a named safe contact to call on your behalf to arrange support

Contact Details for the Victim

Agency Referral - Person under age 15 (Other agencies)

Please note we cannot make contact or hold any information without consent of the ‘data subject’. Please seek consent and re-refer using this form or contact us on 0300 3030 1977

Contact Details for the Victim

Equality, Diversity & Inclusion

Alleged Perpetrator Details

Immediate Safety Needs

If Yes, please call us on 0300 303 3778

Data use/collection

New Era is a confidential service but on occasion we may be asked to share your information with other agencies. Do you consent to us sharing your details with any of the following

There may be occasions we need to share your details without your explicit consent for safeguarding and/or legal purposes. Please refer to our Privacy Notice on www.victimsupport.org.uk

Thank you for referral

We aim to respond within 2 working days

Upload your support files