Sanctuary Scheme Professional Referral form

  • Home
  • Sanctuary Scheme Professional Referral form

The Sanctuary Scheme enables survivors of domestic abuse to remain in their home, maintain safe and secure housing, and help prevent homelessness, through the provision of home security measures. RISE are grateful to BHCC for funding the scheme.

Sanctuary Scheme Professional Referral form

If you are looking to refer yourself into RISE services, please use the self-referral form

If you are a professional referring someone you are working with to all RISE services, please use the professionals referral form

Sanctuary Scheme Professional Referral form

Please answer the following questions to allow us to assess eligibility and risk

Safeguarding - Adult

Has this person been heard at MARAC in the last 3 months? *
Date person heard at MARAC: *
What is the DVA risk to this person? *
How was this risk assessed?
You said that the person has not been heard at MARAC, but you have also said the risk is HIGH. Have they been referred to MARAC? *

⚠️ Please pause and refer to MARAC

Based on your response, this case has been assessed as high risk but no MARAC referral has been made.

Please return to complete this form once a MARAC referral has been made.

Please confirm

Safeguarding - Children

How many children does this person have living with them, whether some or all of the time? *
GDPR and Consent
Date of Birth *
Client Address
Is it safe to (tick all that apply): *
Client GP Address
Property Tenure:
Please tick which of the following applies:

Suitability for The Sanctuary Scheme

Is there a Restraining Order, Non-Molestation Order, or Occupation Order in place? *
Does the alleged perpetrator have a legal right to occupy the property?
Does the alleged perpetrator live at the property with the victim/survivor? *

⚠️ Perpetrator Present

Unfortunately we are not able to provide Sanctuary options when the alleged perpetrator resides at the property.

Fire Safety

Is there a risk of arson?  *
Have you referred the client to East Sussex Fire and Rescue Service for an enhanced risk assessment?

Landlord Information

Please add one entry for each child involved. If you don’t know the details, enter ‘Not known

Child Details
Child's date of birth
If you don't know the date of birth, tick this box

Use the button below to add information for each child

To help us meet your client's needs, please give us some more details about them

Sex/Gender - tick all that apply
Sexual Orientation
Is your client okay communicating in English?
Does your client need an interpreter?

Does your client have any of the following accessibility requirements?

Tick all relevant boxes

Your clients ethnicity

White:
Black
Mixed Race/Multi Ethnic
Asian

Additional Support Needs:

Household details

Add an adult member of the household

Agency Involvement

Please give details of any agency the client is involved with currently (including the name of any workers and their contact details), e.g. Social Worker, Probation Officer, etc.
Please tick all that apply

Alleged perpetrator details

Name and any known aliases:
Date of birth:
Address:
Have the police taken any action against the alleged perpetrator?
Has the survivor/victim taken any action against the alleged perpetrator?
What do you think is required to help keep the person you are referring safer in their home?
If you have said yes to video doorbell, please confirm the following:
Do you want to receive a copy of this referral to your email inbox? *