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Your email *
Your name*
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’
Other – please state: