Professional Referral Form Is the person you are referring aware and have they consented to you referring them to the Devon Domestic Abuse Alliance?
If not, please explain why consent is not present and on which ground you are making the referral (please note that we may not be able to respond to this referral without evidence of informed consent):
Part 1 – General data on person being referred
Police Crime Reference Number (if applicable)
Please note that there is an expectation that all professionals competed a DASH risk assessment to inform this referral. Have you competed a DASH?
Have you completed a MARAC Referral(on DASH score of 14+ and/or on professional judgement if known)?
Has there been a previous MARAC Referral if known:
Address
Country
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What is the relationship to the person causing harm:
What is the living Situation:
Are there any children in the Household:
List Childrens Full Names and Date of Birth
Does the person being referred or professional have any concerns about their Mental Health (including suicide risks):
Does the person being referred have a disability, Learning, or Communication Needs:
Are they / could they be pregnant:
Do they have unsettled immigration status/ are they asylum seeking or a refugee:
Is an interpreter Required:
Do they have any other communication needs:
Part 2 – Summary of Risks for the person being referred
Risk & Safeguarding Factors
What is your professional judgement as to the person being referred around the risks they face:
Please give initial views on risk including any initial observations:
Has there been a recent escalation in abuse:
Please can you give a summary of the types of domestic abuse experienced:
Are any criminal justice orders in place or other factors that have implications on risk such as police bail or family court arrangements: If yes please give details if known
What does the person being referred want to happen and what outcome would they like
Part 3 – Details on the person causing harm
Person Causing Harm (If Known)
Address
Country
Select Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belau Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Saint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Cook Islands Costa Rica Croatia Cuba Curaçao Cyprus Czech Republic Democratic Republic of the Congo (Kinshasa) Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Ivory Coast Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao S.A.R., China Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palestinian Territory Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Republic of the Congo (Brazzaville) Reunion Romania Russia Rwanda Saint Barthélemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin (Dutch part) Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia/Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom (UK) United States (US) United States (US) Minor Outlying Islands United States (US) Virgin Islands Uruguay Uzbekistan Vanuatu Vatican Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe
Any known risk factors / Any criminal history:
Does the person causing harm have any physical, learning or communication difficulties:
Does person causing harm suffer from poor mental health:
Is the person causing harm threatening or at risk of suicide:
Does the person causing harm receive any support for their mental health problems:
Does the person causing harm need a translator:
Please give any further details or information that may be relevant:
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