GDASS

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Group work referral form: Freedom / Phoenix / Breathe

Date of referral

Referrer name

Referrer agency

Contact details

Referral for (state Freedom, Phoenix, or Breathe):

Client's name

Date of birth

Contact number

Address

Alleged perpetrator's name

Alleged perpetrator's DOB

Alleged perpetrator's address

Alleged perpetrator's description

Alleged perpetrator's car (make/model/reg)

Children's details

Name

Date of birth

School

Gender

Male

Female

Name

Date of birth

School

Gender

Male

Female

Name

Date of birth

School

Gender

Male

Female

Name

Date of birth

School

Gender

Male

Female

Name

Date of birth

School

Gender

Male

Female

Please detail any social care involvement

History

Is the client still in a relationship with the Alleged Perpetrator (AP)?

Yes

Please provide information around the abusive behaviour, please try and include dates where possible

Has the Alleged Perpetrator used weapons against client and/or others?

Yes

If yes, please give details

Does the Alleged Perpetrator have a criminal history/conviction(s) for violence?

Yes

If yes, please give details

Has there been any threats or violence towards professionals by either the client or Alleged Perpetrator?

Yes

If yes, please give details

We cannot guarantee a place on the course until GDASS have reviewed all of the referrals to ensure that the group is suitable for all. If your client is not offered a place on the course we will discuss their options around support which may be more suitable to meeting their needs.

Please be aware the referral cannot proceed if information on this form is not complete.
If you have any questions, contact GDASS on 0845 602 9035.

Contact us

Phone: 01452 726570 or Email: support@gdass.org.uk.

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