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Please enter your details as a referrer, how you are involved with the person, and how you know them (your name, your email address, your contact phone number)*
Has this person consented to this referral?*
If no, is this a best interest referral?*
We're sorry we can only take your referral if the person has consented, or if it is a best interest referral.
Please explain why*
Is the person aged 18 or over?*
Do they have a learning disability?*
Do they live in S Birmingham? Northfield, Edgbaston, Selly Oak or Hall Green*
What’s their first name?*
What’s their surname?*
What's their date of birth?*
What’s their address?*
Address line 2
Town*
Postcode*
What’s their phone number?
What’s their email address?
What’s their ethnic group?
What’s their gender?
Why are you referring them to CASBA? What is the presenting issue?*
Please answer the below Risk Assessment questions as best as you can (please note all data is protected as per our Privacy Policy)
Verbal abuse or threatening language*
Aggressive or intimidating behaviour*
Problems with working with either female or male staff*
Pets on the premises
More information about pet – are they safe and manageable?
Accidental fire setting/arson*
History of rape or sexual assault*
Drug or alcohol misuse*
Financial exploitation or abuse*
Concerns related to mental health*
History of criminal or anti-social behaviour*
Lone working considered unsafe*
Risk when working in groups (risk to self or others)*
Self-harm, self-neglect, suicidal thoughts/behaviours/ideations’*