Professional's Victim Referral — Family Intervention Counselling Service (FICS)

PLEASE COMPLETE THE FOLLOWING DETAILS ON BEHALF OF YOUR CLIENT AND EMAIL ANY ADDITIONAL INFORMATION TO

admin@interventionservice.co.uk

Referrer's Details

First Name

Last Name

Phone

(###)

###

####

Organisation

Client's Information

First Name

Last Name

Date of Birth

YYYY

Is it safe to contact the client by:

Phone

Text

Leave voice messages

Phone

(###)

###

####

Address

Gender

Sexuality

Nationality

Marital Status

Religion

Who does the client live with?

Is the client pregnant?

If so, when is the due date.

Please give names, ages, DOB of the client's children, and their gender.

Does the client require referrals for any additional needs (e.g., services for homelessness, parenting issues, drug misuse, social and community support, finance and benefit).

Does the client have any long-standing illnesses, disabilities or infirmities?

Has the client's case been referred to MARAC?

If yes, please state date.

Is the client experiencing depression, anxiety, self-harm or other mental health issues?

Is the client currently using prescribed drugs?

If yes, please give details.

Is the client currently using or have ever been dependent on illegal drugs or alcohol?

If yes, please give details.

Has the client ever thought or taken suicidal action?

If yes, please give details.

Does the client have any convictions/cautions/warnings against them?

If yes, please give details.

Has the client ever had problems with being violent or aggressive towards others?

If yes, please give details.

Is the client receiving any counselling or mental health services?

If yes, please give details.

Is the client required to attend any other services or courses?

If yes, please give details.

Please state what you hope therapy will achieve for the client:

Please give any recommendations for the work:

Please confirm that the information given is correct and that you have obtained the client's permission for this referral.