Pathways to Change Self-Referral Form

Individual being referred

If a client is awaiting a criminal outcome or is on bail, the referral may not be accepted until the matter is resolved.

Name(Required)

First Last

Date of birth(Required)

Ethnicity(Required)

Sexual orientation(Required)

Gender

Religion

Address(Required)

Address line 1 Address line 2 City County Postcode

Contact number(s)(Required)

Email address(Required)

Do you require an English interpreter?

Yes
No

Language required

Do you have a disability?(Required)

Yes
No

Describe any additional requirements due to disability or sensory needs?

Services involved with

Are Children's Services involved?(Required)

Yes
No
Not sure

Social worker name (if known)

Phone

Email

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

Are CAFCASS involved?(Required)

Yes
No
Not sure

CAFCASS worker name (if known)

Phone

Email

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

Are you involved with or being supported by any other professionals?

Vulnerabilities

Do you have any additional vulnerabilities, such as substance misuse or mental health issues?

Current partner details

Are you currently in a relationship?(Required)

Yes
No

Name(Required)

First Last

Current partner date of birth(Required)

Current partner age

Current partner ethnicity(Required)

Current partner sexual orientation(Required)

Religion

Gender

Current partner address(Required)

Address line 1 Address line 2 City County Postcode

Current partner contact numbers(Required)

Email

Does your partner require an interpreter?

Yes
No

Language required

Relationship status

Length of relationship (years)

Length of relationship (months)

Are there domestic abuse concerns with this relationship?

Yes
No

If no, please complete details below of the relevant individual where concerns have been raised.

Ex-partner details

(please complete if applicable)

Name(Required)

First Last

Ex-partner date of birth(Required)

Ex-partner age

Ex-partner address(Required)

Address line 1 Address line 2 City County Postcode

Ethnicity(Required)

Sexual orientation(Required)

Gender

Religion

Ex-partner contact number(Required)

Email

Does your ex-partner require an interpreter?

Yes
No
Not sure

Language required

Relationship status

Length of relationship (years)

Length of relationship (months)

Are there domestic abuse concerns with this relationship

Yes
No

Children

Children details

Name	DOB	Gender	Parent(s) child is living with and who has parental responsibility

Specifics details of domestic abuse incidents

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.(Required)

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.

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Individual being referred

Services involved with

Vulnerabilities

Current partner details

Ex-partner details

Children

Specifics details of domestic abuse incidents

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