Axis Referral Form

Axis Referral Form

Referral Information

When completing this referral form, please note the following:

Any question marked with an * is mandatory, and required for the form to be submitted
Please complete as much information as possible as this will ensure that we can limit the information that we need to ask the survivor for.

Axis is a survivor focussed organisation, and as such, we reserve the right to not accept referrals for anyone who has been accused, reported, investigated or convicted of any sexual, domestic or violent offences, or anyone who may pose a risk of harm to others.

Referral Information

Are you referring yourself or someone else?

Are you a family member, or professional?

Are you from the Police, or other organisation?

Is the person being referred and adult (18+) or a child (17 and under)

Has the client experienced sexual abuse, domestic abuse or both?

Have you completed a DASH RIC assessment AND are referring to MARAC?

Are you the police and referring due to a DVPO or DVPN bring issued?

Important Message

We can only accept IDVA referrals with a High Risk DASH or if a Domestic Violence Protection Order or Domestic Violence Protection Notice has been issued by the police.

Please upload a copy of the DASH/ DVPO/ DVPN

Referrer Information

Confirmation that the person being referred has consented to the referral and agrees for Axis to make contact

Important Message

We are unable to accept referrals without consent.

Referring organisation category

Name of referring organisation

Referrer name

Referrer phone number

Referrer email

Relationship to person being referred

Client Information

Title

First Name

Middle Name (s)

Last Name

Known As

Date of Birth

First Line Address

Town/City

County

Postcode

Location area

Permission, and safe to contact by post?

Primary Contact Number

Safe to call? (Primary)

Reveal number when calling? (Primary)

Safe to leave a message? (Primary)

Safe to text? (Primary)

Secondary Contact Number

Safe to call? (Secondary)

Reveal number when calling? (Secondary)

Safe to leave a message? (Secondary)

Safe to text? (Secondary)

Email Address

Is it safe to contact by email?

Emergency Contact Name

Emergency Contact Number

Children/Young Person (CYP)

Is the Client in Care?

Parent / Carer / Guardian 1

Relationship to client

Title

First Name

Last Name

Address (Street)

Address (City)

Address (County)

Address (Postcode)

Primary Contact Number

Secondary Contact Number

Email Address

Special Contact Instructions

Parent / Carer / Guardian 2

Relationship to client

Title

First Name

Last Name

Address (Street)

Address (Town/City)

Address (County)

Address (Postcode)

Primary Contact Number

Secondary Contact Number

Email Address

Special Contact Instructions

Education Establishment

Educational Setting

Name of Educational Setting

Contact Name

Contact Number

Contact Email

Demographics

Ethnicity

Nationality

Immigration Status

Primary Language

Interpretor Required

Marital Status

No. of Dependants

Gender

Client gender different from birth?

Pronouns

Sexual Orientation

Religion

Employment Status

Accomodation

Presenting Factors and Risks

Presenting risks - Potential dangers that the client may face.

To select more than one option, click and drag to highlight multiple items, or hold down the Ctrl key (Windows) or Command key (Mac) while clicking each option you want to select.

Presenting harms - Current dangers that are already occurring

To select more than one option, click and drag to highlight multiple items, or hold down the Ctrl key (Windows) or Command key (Mac) while clicking each option you want to select.

Presenting factors - Factors that the client is presenting with

To select more than one option, click and drag to highlight multiple items, or hold down the Ctrl key (Windows) or Command key (Mac) while clicking each option you want to select.

Mental Health Diagnosis

To select more than one option, click and drag to highlight multiple items, or hold down the Ctrl key (Windows) or Command key (Mac) while clicking each option you want to select.

Does the client have a disability (other than a learning difficulty/ disability)

Details of Disability

To select more than one option, click and drag to highlight multiple items, or hold down the Ctrl key (Windows) or Command key (Mac) while clicking each option you want to select.

Are any special requirements needed to support client to access service?

Does the client have a learning difficulty/ disability?

Details of Learning Difficulty/ Disability

To select more than one option, click and drag to highlight multiple items, or hold down the Ctrl key (Windows) or Command key (Mac) while clicking each option you want to select.

Are any special requirements needed to support client to access service?

Are you aware of any safeguarding risks?

Details of safeguarding risk

Does the client present any risks (i.e sexual offending, violent offending) that we need to consider to keep our staff and other clients safe?

Details of risk

Have you ever been accused, investigated, charged or convicted of a sexual offence?

Please provide details

Have you ever been accused, investigated, charged or convicted of a violent offence (including domestic abuse)?

Please provide details

Incident

Crime reference number or incident log number

Date of incident or start date

Approx date/ range if not known exactly

Location of incident

Age at time of incident

Reported to the police?

Police force reported to

Date reported to the police

Investigating Officer or Officer in the case (OIC) full name and collar number

Investigating Officer or Officer in the Case (OIC) phone number

Investigating Officer or Officer in the Case (OIC) email

What stage of the Criminal Justice Process is the case at?

Next court date

Primary incident category

Summary of the incident

Provide any relevant information about the investigation, allegation or current situation

Perpetrator First Name

Perpetrator Last Name

Perpetrator Gender

Perpetrator Date of Birth

Perpetrator age (if DOB not known)

How is the perpetrator related to the client?

Has a forensic examination taken place?

Forensic examination date

Other information

Other support agencies involved?

Agency 1

Organisation Name

Organisation Contact Name

Contact Telephone Number

Contract Email Address

Agency 2

Organisation Name

Organisation Contact Name

Contact Telephone Number

Contract Email Address

Agency 3

Organisation Name

Organisation Contact Name

Contact Telephone Number

Contract Email Address

Sexual health clinic attended?

Where did you hear about Axis?

Axis service requested

On another counselling waiting list?

Preferences

Does the client have a preference for gender of worker?

You cannot submit this referral unless consent has been confirmed (Yes).