South Essex Rape and Incest Crisis Centre (SERICC)
Early Offer Referral Form
2014
Thurrock Early Offer and Prevention Services Criteria
Thurrock women who have been a victim/survivor of child sexual abuse, sexual violence and / or sexual
exploitation, who have children and are an open case to Thurrock social care, can be referred to SERICC as
part of our Early Offer and Prevention Service.
Referral Process
Completed referral forms can be emailed – password protected to sericc@sericc.org.uk or sent by secure
email: sericc.secure@sericc.cjsm.net or faxed to 01375 387053. It is important that the client is made aware
of the referral as contact will be made direct with the client. SERICC’s Early Offer Service provides specialised
services intended to support and equip families to learn and apply parenting skills that develop
resourcefulness and resilience while strengthening positive relationships with their children.
Please confirm that it is safe to contact the client by telephone or send literature by post and that
they are aware of the referral. If it is not safe then please provide alternative safe contact details.
*Please delete as appropriate
REFERRING ORGANISATION:
NAME OF PERSON MAKING REFERRAL:
REFERRER’S TEL NO.
REFERRAL DATE:
CLIENT’S CONTACT NO:
CLIENT’S NAME:
CLIENT’S ADDRESS:
TOWN:
POST CODE:
Ok to send mail
YES
NO
Ok to leave a telephone
message?
YES
NO
ALTERNATIVE CONTACT DETAILS:
CLIENT DATE OF BIRTH:
ETHNICITY:
LANGUAGE:
IMMIGRATION STATUS:
GP:
INTERPRETER REQUIRED:
YES
NO
LIVING WITH: *ALONE / *PARTNER / *CHILDREN /*PARENTS / *RELATIVE / *CARER
Unemployed
Employed
Home
Owner
Student
Please provide partner’s details - if living with
partner:
Private
Renting
NUMBER OF DEPENDENTS:
(under 18s)
CHILD’S NAME:
D.O.B
CHILD’S NAME:
D.O.B
CHILD’S NAME:
D.O.B
MALE
Local
Authority
FEMALE
SERICC adhere to a Confidentiality, Data Protection and Safeguarding Policy which is available on request.
South Essex Rape and Incest Crisis Centre (SERICC)
Early Offer Referral Form
CHILD’S NAME:
D.O.B
CHILD’S NAME:
D.O.B
CHILD’S NAME:
D.O.B
INTERVENTION:
IDENTIFIED RISKS:
*CHILD IN NEED
2014
*CHILD LOOKED AFTER
*CHILD PROTECTION
*CHILDHOOD SEXUAL ABUSE
*SEXUAL VIOLENCE
CLIENT DISABILITY: If a client considers themselves to have a disability please select the most appropriate
definition. If the client has multiple disabilities please select the definition that reflects the predominant disability.
Not Considered Disabled
Mental Health Issues
Other
Physical Impairment
Learning Disability/Difficulty
Unknown
Sensory Impairment
Long Standing Illness or
Health Condition
Other Please state:
STATUTORY FRAMEWORKS
DOES THE SERVICE USER HAVE ANY INVOLVEMENT WITH THE FOLLOWING:
MARAC
Probation / Youth Offending
CAF
MAPPA
Care Management
Homeless
ASBO
Care Programme Approach
Other – please state
Drug Intervention
Child in Need
PLEASE NAME ANY OTHER ORGANISATIONS OR WORKERS INVOLVED IN THE SERVICE USERS
WELFARE e.g. CORAM, Women’s Aid, Family Intervention Project (FIP) etc.
PLEASE LIST ANY FURTHER INFORMATION OR ISSUES RELEVANT TO THIS REFERRAL
ARE YOU AWARE IF THE WOMAN HAS PREVIOUSLY USED SERICC’S
SERVICES?
YES
NO
Ways to Return this Form
SERICC adhere to a Confidentiality, Data Protection
Safeguarding
Policy which is available on request.
BY FAX:and
01375
387053
By Password Protected Email: sericc@sericc.org.uk