Threshold DAS

32 Station Road, Llanelli

01554 752422
E3

Agency Referral Form

Choices delivers a programme of one-to-one and group sessions for

perpetrators of intimate partner violence alongside a support service for
partners/ex-partners and their children or young people.

It is important that the details of the perpetrators current and ex-

partners are given to use for safety reasons. Please ensure that you have
entered these details to avoid delays in service.

Choices is for clients who…

- Live in Carmarthenshire/Swansea
- Agree to be assessed for their suitability for the programme
- Can attend regular sessions – usually weekly – for approximately 30 weeks
- Understand that their partners/ex-partners will be offered a support service

Please contact us before referral if you client is currently…

- Awaiting the outcome of a criminal justice process

- In legal proceedings over child contact
- Undertaking or waiting to start another Domestic Abuse program
- Attending counselling and/or therapy
- Subject to child protection orders.

Once completed please email this referral form and all

supporting documents to: enquiries@threshold-das.org.uk
Client Information:

Client Name Rhys burgess

Date of Birth 27/09/1992
Address 49 coryton close Post
Brecon Code
Powys
Ld3 9hp
Telephone Number(s) 07597215773
Email Address Rhysb1234@hotmail.co.uk
Employment Status Full Time employment
Ethnicity White British
Has the client consented Yes ✘ No
to this referral?

Name of Client’s Current parent:

Name Natasha Morgan

Date of Birth 2/1/1980
Address 1 Bryn de winton Post
Brecon Code
Powys
Ld3 9hl
Telephone Number(s) +44 7969 769033
Email Address
Employment Status Full time employment
Ethnicity
Are they still in a relationship with the client? Yes ✘ No
Are they aware of the referral? Yes ✘ No

Name of Client’s Ex-Partner:

Name
Date of Birth
Address Post
Code
Telephone Number(s)
Email Address
Employment Status
Ethnicity
Are they still in a relationship with the client? Yes No
Are they aware of the referral? Yes No
Registered in Wales as a Company Limited by Guarantee: No 6388297
Registered as a Charity: No 1124149. Registered Office: 32 Station Road,
Llanelli, Carmarthenshire, SA15 1AN
Referrer’s Details:

Name Date
Agency
Address

Telephone
Number
Email Address

Does the client or partner have any additional requirements?

(For example: an interpreter or wheelchair access)

Yes No ✘

Please specify:

Click here to enter text.

Does the client or partner have any mental health issues we should be aware of?

Yes No ✘

Please specify:
(What are these mental health issues and are they formally diagnosed or the clients
perception?)

Click here to enter text.

Is there mental health support in place?

Yes No ✘

Please specify who is supporting the client and their contact details:

Click here to enter text.

Registered in Wales as a Company Limited by Guarantee: No 6388297
Registered as a Charity: No 1124149. Registered Office: 32 Station Road,
Llanelli, Carmarthenshire, SA15 1AN
Does the client or partner take medication?

Yes No ✘

Please state who (client or partner) takes the medication and what medication they
are on:

What are the client’s motives for wanting a referral to our Program?

Click here to enter text.

To get help to change my behaviour to be able to be a good person and partner

Date and details of the most recent incident with the partner/ex-partner:

Click here to enter text.

August 24th an argument and threats were made

Registered in Wales as a Company Limited by Guarantee: No 6388297

Registered as a Charity: No 1124149. Registered Office: 32 Station Road,
Llanelli, Carmarthenshire, SA15 1AN
Current Family Details:

Please select the current relationship status with their partner:

Married Cohabiting Divorced Separated

Other (please specify): Click here to enter text.

Detail of any children with current partner:

Name of Child Gender Date of Birth Relationship to Client Where does the child live
(father/step-father)

Detail of children from other relationships:

Name of Child Gender Date of Birth Relationship to Client Where does the child Name of child’s
(father/step-father) live mother
Are there any outstanding or ongoing court proceedings? Public (criminal) or
private?

Yes No ✘

Please specify:

Click here to enter text.

Are there any orders prohibiting the client from having contact with his partner
or children?

Yes No ✘

Please specify:

Click here to enter text.

Are there any other safeguarding measures?

Yes No ✘

Please specify (Please ensure you attach/send any relevant safety plans such as CIN):

Click here to enter text.

Is there any involvement from other agencies?

Yes No ✘

Please specify:

Click here to enter text.

Is the client or partner currently engaging with, or been referred for, any other
form of therapy or counselling?

Yes No ✘

Please specify:

Click here to enter text.

Has the client or alleged victim ever been to a MARAC?

Yes No ✘

Please specify:

Click here to enter text.

Has the client previously been referred to, started or completed any other
Domestic Violence Perpetrator Programme?

Yes ✘ No

Please specify:

Click here to enter text. Through Probation service

Has the client consented to information sharing?

Yes No ✘

Please explain if response is “No”:

I don’t feel comfortable with that

Registered in Wales as a Company Limited by Guarantee: No 6388297

Registered as a Charity: No 1124149. Registered Office: 32 Station Road,
Llanelli, Carmarthenshire, SA15 1AN
Is there anything else we should be aware of?

This is a self referral

Registered in Wales as a Company Limited by Guarantee: No 6388297

Registered as a Charity: No 1124149. Registered Office: 32 Station Road,
Llanelli, Carmarthenshire, SA15 1AN