Shirley Community Chaplaincy (North East)

General Referral Form

We ask the following questions so that we can help and support you in the community and, if
necessary, help you to get the help you may need.

Your Contact Information:

Full Name (please indicate preferred first name or nick name)

Home Address:

Phone Number:
Land line
Mobile

Date of Birth

Relationship Status:
Single/ In Relationship / Married / Divorced / Widowed / Other /
Prefer not to say
If current location:
HMP Northumberland/ HMP Durham / HMP Low Newton
Inmate Reference Number:

Offender Manager Details:

Probation Officer's Name:

Contact Information:

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Next of Kin details:
Name
Address

Phone Number
Your Relationship to the next of kin:
Spouse / Partner / Family Member / Friend / Other
Are there any restrictions in contacting your next of kin? Yes/No

Background Information
Offence Details:

Total Sentence: Years /

Months
Court:
Newcastle / Teeside / Carlisle / Preston
Manchester / Leeds / Other

Date of Sentence:

Expected Release Date

End of licence Date
Did you have any history of violence / DV? Yes/No
If so, please give brief details:

Have you done any anger management courses? Yes/No

Do you have any history of sexual offences? Yes/No
If so, please give brief details:

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Have you had any courses such as STOP? Yes/No
If so, please give brief details:

Do you have / expect to have any restrictions on your licence? Yes/No

If so, please give brief details:

Does this include any places / locations?

If so, please give brief details:

Health Issues:
Do you have any long standing health issues? Yes/No

If so, please give brief details:

Do you have any mental health issues? Yes/No

If so, please give brief details:

Have you received help in the community/ CPN / Crisis team or Yes/No
equivalent?
If so, please give brief details:

Have you any current alcohol or drug issues and are you attending Yes/No
treatment programmes?
If so, please give brief details:

Please let us know if you are receiving drug treatment medication.

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Have you received help in getting off alcohol or drugs in the past? Yes/No
If so, please give brief details:

Do you / or will you receive any support after you leave prison? Yes/No
If so, please give brief details:

Is there any other information that you would like to tell us?
Have you been offered a job / place on a scheme or college? Yes/No
If so, please give brief details:

While you were inside, did you act as a mentor? Yes/No

If so, please give brief details:
DART/ Toe by Toe / Listener / Other

Do you have any hobbies that you would like to continue after Yes/No
you are released?
If so, please give brief details:

We may be help able to organise group activities or put you in Yes/No

touch with a group. Would you be interested?
Would you like to help you get in touch with a place of worship? Yes/No
If so, please give brief details

Have you any previous contact with a place of worship? Yes/No

If not, would you like us to help you contact a minister/priest Yes/No
(or equivalent)?

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Consent
I confirm that the information that I have supplied is, as far as I am
aware, correct. I confirm also that I am happy for the Shirley Community
Chaplaincy (North East) to contact me with information and invitations
and to seek my help.

Please print your full name

Signed
Date
The above person was referred by

Confidentiality Clause

The Shirley Community Chaplaincy (North East) is committed to team working both
within the Chaplaincy and in co-operation with other relevant agencies. We maintain
information in accordance with the General Data Protection Regulation 25 May 2018
and, where possible, will contact you to obtain your consent if we need to share
information with a third party.

The main exceptions are outlined below:

- If we believe that you are at risk to yourself / others as a result of your Mental
Health
- If we believe there are safeguarding issues where you are at risk or a risk to others
- If we are required to provide evidence in a criminal investigation concerning
current / historical offences
- If we need to provide emergency medical / next of kin information in the event of
you being taken ill or having a serious accident.
- If we are issued with a court order and required to provide information.

(For further information, please refer to the Shirley Community Chaplaincy’s

Confidentiality Policy, Privacy Notice, and Safeguarding Policy).

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Monitoring Information

Sex / Gender Male Age Group Under 20

Female 20 – 24
Trans-gender Related 25 – 29
30 – 34
34 – 39
40 – 49
50 – 65
Over 65
Originally From Scotland Will be returning Scotland
North East England eventually home to: North East England
North West England North West England
Midlands Midlands
South East England South East England
South West England South West England
Wales Wales
Northern Ireland / Eire
Northern Ireland / Eire
Travelling Community
Travelling Community
Europe
Abroad
America / Latin America
Africa
Asia / SE Asia
Australasia
Caribbean
Middle-East
Russia / Baltic
Length of Sentence Under 1 year Nature of Offence ABH / GBH / DV /
1 – 2 years Violence
3 – 4 years Manslaughter / Murder
Over 4 years Sexual
Life Burglary
IPP Driving Related
Drug or Alcohol related
Fraud Related
Arson Related
Other
Disability? Yes / No Have you ever served in No /
the armed forces? TA / Regulars
Alcohol History? Yes / No
Drug History? Yes / No
Mental Health History? Yes / No
How did you hear about Chapel
us? Prison Poster / News Letter
Via a Friend / Member of your family