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.

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

People who live in Brighton and Hove or have been housed temporarily by Brighton and Hove City Council in another local authority area 
People who have been impacted by some form of DA in their lives, and require support to maintain safe and suitable accommodation 
People who consent to being contacted by us to discuss their support options in relation to their experience of domestic abuse specifically 

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
GDPR and Consent
All information is confidential and stored securely on the RISE servers. Information is only shared with third parties with the explicit consent of the person being referred or if there is a risk of significant harm/safeguarding concerns 
Client 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:

Household details

Add an adult member of the household

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?
ESFR Referral Form

Landlord Information

Safeguarding - Children

How many children does this person have living with them, whether some or all of the time? 
Confirm safeguarding actions 
Child Details

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

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:

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:
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?