RESET Professionals Referral Form

We can only accept referrals with consent. If you don't have consent but you do have safeguarding concerns, please contact the RESET team on freephone 0800 915 9357 or request a call back.

Referrer details

Name of Referrer(Required)

Name of Agency:(Required)

Job Title(Required)

Date of Referral(Required)

Contact Number(Required)

Email Address(Required)

About the person I would like to refer

Name

Preferred Name

Do you have the consent of this person to make this referral?(Required)

We can only accept referrals with consent.

Yes

Best way to contact

Information to include method of contact, times of contact or barriers to contact

Address

Phone

Date of Birth(Required)

Employment status(Required)

Gender(Required)

Sexuality(Required)

Ethnicity(Required)

Religion(Required)

What is their main language?

Are there any diversity or wider support needs?

Person who is being harmed

Reason for referral

Has a DASH RIC been completed recently?

Yes

Please provide score and date completed if known

Are they any specific risks (where indicated include level of risk e.g. MARAC, MAPPA ) that you are aware of?

Are other professionals involved?

Adult Social Care

Name of Social worker

Contact Details

Children’s social care

Name of Social worker

Contact Details

Other Agency involvement

List

Service Name

Allocated Worker / Contact Name

Contact Details

Is there any other information you think we should know which is relevant to referral?

RESET Professionals Referral Form