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The information you enter into this form will be collected and stored by Step Together Volunteering. By continuing with this referral, you agree and accept to share this information.
Please note that questions marked with this sign * are compulsary
1. Which Client Group would like to make a referral for?*
Please complete details about the person you are referring to us, including if this is a self referral
2. Client First Name(s)*
3. Client Surname*
4. Pronouns*
5. Client DOB*
6. Client National Insurance Number (This information is only required for Ex-Offender Referrals. If you are referring someone for a different client group and would not like to include the NI Number, please put 'N/A')*
7. Client Address: Line 1*
8. Client Address: Line 2*
9. Client Address: Line 3*
10. Client Address: Town*
11. Client Address: County*
12. Client Address: Postcode*
13. Client Main Phone Number*
14. Client Email Address*
15. Best method of contacting client*
16. STV are aware that domestic abuse may escalate when external agencies become involved in victims lives, is it safe to leave messages, text etc?*
17. We may occasionally contact a client via a letter through the post and understand that sometimes for our clients this might not be a preferred or safe option. Is it safe for STV to post letters?*
18. Emergency Contact Name and relationship to client*
19. Does the emergency contact use the client's chosen name or another? (If another, please let us know what name is preferred)*
20. Emergency contact - Phone number*
If you are referring on behalf of someone else, please complete your contact details below. If you are making a self-referral, please enter 'N/A'
21. Referrer Name*
22. Referrering Organisation*
23. Referrer’s Relationship to Client*
24. How long have you (the referrer) been working with your client?*
25. Referrer Contact Details (Name, Address, Phone Number, Email Address)*
26. Please provide details of other organisations supporting the client if applicable
Questions 27 - 33 are for Ex-Offender Referrals, made on behalf of someone else only. If you are making a self referral or a referral for a different client group, please go straight to question 34. This form is to be used for referrals for someone with a criminal record whose offence has occurred in the last five years &/or who has been recently released from custody.
27. Date of release from prison or start date of community order:
28. Current Offence
29. Sentence Expiry Date
30. Length of sentence
31. License conditions – e.g. exclusion zones / curfew etc.
32. Probation Officer (If applicable)Address / Contact Number / Email
33. Risk Assessment: Risk of Re-offending
34. Please tell us more about the client's current living situation and how they are supporting themselves (Please include if they are living with others)
35. Please tell us more about the client's current employment/ training/ education situation:*
36. Does the client have any additional support needs?Please tell us about any physical disabilities, learning needs, mental health needs, alcohol or substance use concerns etc. Please include how they manage these and how they may affect volunteering.
37. Does the client have a criminal record that you know of?*
38. If the client does have a criminal record, please give more detail below.
39. Please tell us why you are referring the client to Step Together Volunteering (Please use this area to summarise the reason for referral to Step Together. You should include as much detail as possible to help us establish the correct level of support needed.)*
40. Is the client serving, a Veteran or a Family member of an injured service person?
Thank you for completing this referral form – we will aim to respond within the next 5 working days.
Accommodation Type