HIDDEN TEST – Hampton Trust

Location*

Name*

First Last

D.O.B*

Age*

Ethnicity

Sexual Orientation*

Gender

Immigration Status

Religion

Address*

Street Address Address Line 2 City County Postcode

Contact Number(s)*

Do you have a disability if so, what is your disability?*

Do you have any special requirements or needs ?*

(e.g sensory , mobility, literacy ect)

Email Address*

Referrer Information (if not a self-referral)

Have you (the referrer) completed the 3-Module Hampton Trust Dare Training?

Yes
No

Name*

First Last

Agency

Phone

Email

Any other information

Has the person being referred given consent for this referral?

yes
no

Please note we will not take referrals without consent from person being referred or partners details (partner does not need to consent)

Please confirm this has been discussed with the subject of the referral

yes
no

Is the individual being referred under 18?

yes
no

If yes do they have as YOT worker? please provide details

Is there a child protection plan/child in need plan? please provide details

Do they have a care plan? Please provide details

Services involved with

Children Services Involved

Yes
No

Social worker name (if known)

Phone

Email

Brief history of social services involvement (inc. child protection/court proceedings)

CAFCASS involved?

Yes
No

CAFCASS worker name (if known)

Phone

Email

Legal teams contact details

Phone

Email

What are the contact arrangements for the named individuals seeing the children?

Vulnerabilities

Are they involved with any of the following

Social care worker
Mental Health Worker
YOT/Probation officer
Youth support worker
Family support worker
Solicitor
Other

Please give details of boxes ticked and the agencies/professionals involved

Are they at risk of/ experiencing substance misuse?

yes
no

Current partner details

Are you currently in a relationship?*

Yes
No

Current Partner Name*

Current Partner D.O.B*

Current Partner Age*

Current Partner Ethnicity*

Sexual Orientation*

Religion

Gender*

Current Partner Address*

Street Address Address Line 2 City County Postcode

Current Partner Contact Number*

Email*

Immigration Status

Does your Current Partner require an English Interpreter?*

If yes which language

Relationship status

Length of relationship (years)

Are there domestic abuse concerns with this relationship*

yes
no

Ex-partner Details

Ex-partner Name*

Ex-partner D.O.B*

Ex-partner Age

Ex-Partner Address*

Street Address Address Line 2 City County Postcode

Individual Ethnicity

Sexual Orientation*

Gender*

Religion

Ex-partner Contact Number*

Email*

Immigration Status*

Does your Ex-partner require an English Interpreter?

If yes which language

Are they/you currently on probation?*

Relationship status

Length of relationship (years)*

Are there domestic abuse concerns with this relationship*

yes
no

Children

Children details

Name	D.O.B	Gender	Parent(s) child is living with and who has PR

Please provide a detailed summary of Date, Time, Incident, Summary of incident and outcome for any incidents in the past two years. Prior to this, a list of incidents and dates will suffice.*

In order for the Hampton Trust to offer you support, advice and guidance we will need to process some of your personal data. There are strict laws concerning this. We have a policy on data protection which is published on our website. If you would like a printed copy, please request one from a member of staff. By understanding and agreeing to these privacy terms, you consent to us processing your data for the purposes stated. You may withdraw your consent at any time.

We promise to only process your data to deliver the support or services you need. We will share your data with third parties to ensure the support is right for you and to give you all the options we can. A list of those third parties is available upon request and may be updated from time to time.

If you withdraw your consent and we believe you are at risk, we may on rare occasions continue to process your data in your best interests, in accordance with the Data Protection Act 2018 or where any other legal obligation exists.

Data is retained in accordance with our policies, a schedule of which is available.

Referrer Information (if not a self-referral)

Services involved with

Vulnerabilities

Current partner details

Ex-partner Details

Children

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