RECONNECT Referral Form

Referrals will only be accepted for individuals that require support accessing and engaging with community-healthcare services and/or support services upon their release. This service is not a replacement for any other existing service and will work alongside other agencies to support successful release into the community.

All fields are mandatory unless stated otherwise.

Date of Referral (required)

Name of individual being referred:

Service Name Referral

If ‘Other’ was selected, please confirm the name of the referral - Optional

Prison Number - Optional

D.O.B (required)

Please ensure the consent to share information form has been signed by the individual and is included with this referral

Please confirm the individual is aware of the referral and sharing of information.

Yes (required)

What is the individual’s sex?

Is the gender the individual identifies with the same as your sex registered at birth?

Religion or Belief

Ethnicity

Sexual Orientation

Marital Status

Identified Disability

Pregnancy and Maternity

Armed Service History

Area the individual will be released to:

Home Address - Please indicate if no fixed abode upon release

Family/Personal Circumstances - (e.g. will this person have family support on release, will they live with family? Support of friends etc.?)

Does the individual have any caring responsibilities?

Release date (required)

Current Risk alerts / ACCT Status: - Optional

ROTL dates if known

Is this individual subject to any license conditions? (e.g. geographical tag/curfew etc.)

Does this individual have any restraining orders?

Please identify specific health and treatment needs in the community - (e.g. Accessing Physical Health services, Mental Health / Substance Misuse services)

Is the individual registered with a GP? If yes, please state which GP

What are the identified challenge/s to accessing treatment for this individual

Are there any concerns about a successful transition to the community? (e.g. Anxiety/Previous unsuccessful attempts/Social circumstances etc.)

Are there any risks that the individual poses when engaging with others? e.g. aggressive tendencies, known triggers, previous behaviours etc.

Is this individual under MAPPA/ MARAC? If yes, please include category and level:

Yes

Category - Optional

Level - Optional

Which other agencies are involved in this person’s care?

Offender Manager in Custody details (if applicable)

Probation Officer and contact details (if applicable)

Details of Referrer

Name

Job Role

Contact Number

Email Address

Hertfordshire

RECONNECT Referral Form

RECONNECT Referral Form