An initial assessment of whether the family fit criteria for SHE:
Brief details of the family situation are required in order to assess if we can help.
Information disclosed during this Eligibility Enquiry will be held by SHE and used for their monitoring purposes. This information will also be shared with outside agencies, although the name of the applicant will be kept confidential. Confidentiality will be overridden by disclosures or causes of concern of Child Protection matters, Safeguarding Vulnerable Adults issues or illegal activities. The applicant must agree to this process as part of our Data Protection policy before continuing with the process. Refusal to answer questions will mean that we will be unable to continue the application process.
The SHE Project will empower women and girls to take control of their lives by preventing their future victimisation through delivery of a holistic programme of support for families who are affected by domestic violence and abuse.
The SHE Project aims to:
Name of Agency
Name of Contact
If not a self referral, is the perpetrator aware you are making this referral?
Perpetrator Family name:
Date of Birth
Address & Post Code
Partner (or ex-partner's) family name
Address * Post Code
First Child's Name
First Child's Date of Birth
First Child's Age
Second Child's Name
Second Child's Date of Birth
Second Child's Age
Third Child's Name
Third Child's Date of Birth
Third Child's Age
Fourth Child's Name
Fourth Child's Date of Birth
Fourth Child's Age
What has led to this enquiry about this service?
What support is needed at this time?
Who has been affected by the abuse?
Is anyone at risk of being harmed now?
Please give details
Has the applicant ever attended Counselling/therapy?
Has the applicant experienced previous mental ill-health?
Has the applicant ever received an evaluation for Alcohol/drug dependency?
Has the applicant been involved with the police in any way?
Does the applicant have any bail or convictions pending?
Supporting Professional Contact Details
Agreement to contact this professional?
The perpetrator will be contacted to discuss their eligibility. Eligible applicants will be contacted to do a full assessment.