Redbridge Reach Out Service Referral

The Reach Out service assesses risk, carries out safety planning, and links those who have been affected by domestic abuse to practical and emotional support.

Abusive behaviour is considered domestic abuse if both individuals are over the age of 16 and are personally connected (e.g. in a relationship, separated, relatives). For a full description of what personally connected means please visit the legislation.gov.uk website (opens in a new window)

This referral form has been designed for professionals. If it is safe to do so, please advise the individual that you are making a referral on their behalf before doing so.

The Reach Out service operates from Monday – Friday (9am-5pm). If someone would like to seek help outside of these hours, please encourage them to call the 24-hour national domestic abuse helpline on 0808 2000 247. For access to social care out of hours, you can contact the Adult Emergency Duty Team on 0208 554 5000 or Children’s Emergency Duty Team on 0208 708 5879. In the event of an emergency, please call the police on 999.

If there are children involved, please note that this referral will be passed onto Redbridge’s Multi Agency Safeguarding Hub (MASH).

Professional’s details

First name of worker completing referral(Required)

Last name of worker completing referral(Required)

Position/Title(Required)

Agency/Organisation(Required)

Professional's contact details

Telephone number(Required)

Email address(Required)

Victim/Survivor's details

First name(Required)

Last name(Required)

Date of birth

Victim/survivor's details

Full address

Street Address Address Line 2 City County Postcode

Email address

Victim/survivor's details

Mobile number

Safest time/s to contact the victim/survivor

Victim/survivor's details

Interpreter required?

Yes

No

First language

Ethnicity

Victim/Survivor's disabilities (including Mental Health)

Physical

Sensory

Mental health condition

Learning disabilities

No disabilities

Unknown

Please provide more detail regarding the disability including any support needs we need to take into consideration.

Victim/Survivor's gender

Victim/Survivor's sexuality

Heterosexual/Straight

Gay or Lesbian

Bisexual

Pansexual

Other

Prefer not to say

Unknown

Any alcohol or substance misuse by the victim/survivor?

Yes

No

Please give details of alcohol or substance misuse?

What is the current relationship between victim/survivor and perpetrator?

In relationship

Ex-partner

Separated

Familial (e.g.: child-to-parent)

Unknown

Other

Please state relationship

Children’s details

Do they have children under the age of 18?

Yes

No

Please provide children's details

Child's first name	Child's last name	Date of birth	Address (If different from parents)	Actions

There are no Entries.

Do you know the perpetrator/s details(Required)

Once we have spoken to the victim/ survivor, we will also contact the perpetrator of the abuse if it is safe to do so. If they wish to address their abusive behaviours, we can refer them to our Spotlight Programme.

Yes

No

Are there multiple perpetrators?(Required)

Please let us know if the individual is at risk of abuse from multiple perpetrators; for example, they might be at risk from multiple members of their family or their in-laws

Yes

No

Please provide perpetrator’s details

First name	Last name	Date of birth	Email address	Actions

There are no Entries.

Perpetrator’s details

First name

Last name

Date of birth

Perpetrator’s details

Full address

Street Address Address Line 2 City County Postcode

Mobile number

Email address

Perpetrator’s details

Interpreter required?

Yes

No

First language

Ethnicity

Does the perpetrator have any disabilities (including mental health)

Physical

Sensory

Mental health condition

Learning disabilities

No disabilities

Unknown

Please provide more detail regarding the disability including any support needs we need to take into consideration.

Perpetrator’s gender

Perpetrator’s sexuality

Heterosexual/ straight

Gay or lesbian

Bisexual

Pansexual

Other

Prefer not to say

Unknown

Any alcohol or substance misuse by the perpetrator?

Yes

No

Please give details of alcohol or substance misuse?

Are there other household members?

Yes

No

Unknown

Please provide details of other household members

First name	Last name	Date of birth	Actions

There are no Entries.

Reason for referral

Reason for referring(Required)

Please state any present/historical concerns and describe the perpetrator’s pattern of behaviour (such as physical abuse, sexual abuse, financial abuse, psychological abuse & coercive control).

Is the victim/survivor aware of this referral?(Required)

Yes

No

Is the Perpetrator aware of this referral?

Yes

No

Has the victim/survivor consented to this referral being made?

If no, we will contact them to request their consent

Yes

No

Other professionals

Any other professionals involved?

Worker

Agency

Phone number

Involved with whom?

Risk assessment

Have you already completed the DASH Risk Identification Checklist?

Yes

No

Please upload the DASH Risk Identification Checklist

Accepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 50 MB.