Victim Name:      

WEST MIDLANDS MARAC REFERRAL FORM
NON-POLICE AGENCY

Advice when completing this form
•	Fields marked with * are compulsory and forms will not be accepted without this information. If the mandatory information is not given, the referral will be withdrawn and the referring agency requested to resubmit. 
•	Referral forms will only be accepted in Microsoft Word format.
•	Where a risk assessment tool (such as DASH) has been completed, a copy should be submitted along with the referral form.
•	The referrer is expected to attend the relevant MARAC to present this case and will be invited if the referral is accepted.
•	On completion, this form should be submitted via secure means only to marac_referrals@west-midlands.pnn.police.uk
•	For advice and guidance, please contact the West Midlands Police MARAC Administration team on 101 ext. 811 3048

About this form
This form should be used to submit a MARAC referral when the risk to a victim of domestic abuse has been assessed as high, either through a risk assessment or professional opinion. It should also be used when an already known high risk victim has suffered a repeat incident from the same perpetrator within 12 months after the last MARAC hearing or by the MARAC Administration team when a MARAC victim has transferred into the West Midlands from another area.
When completed, this form will contain personal information (data) including special category (sensitive) data. You, the referrer, are required to comply with General Data Protection Regulations (GDPR) in the processing (including storage & retention) of this data. 
GDPR
Article 5 of the GDPR sets out six key principles which lie at the heart of the general data protection regime. MARAC data will typically be lawfully shared under Article 6 (1) (e) public interest or 6 (1) (f) legitimate interest, depending on whether you are a public sector organisation or voluntary agency. If you are relying on your legitimate interests, you need to be clear as to what these interests are, e.g. your interest in safeguarding victims of domestic abuse, and preventing further victimisation. You will also need to have carried out a ‘balancing exercise’ where you weigh up the interests of the data subject, and the protection of their rights and freedoms, against your own interest. There is further protection where ‘special category’ data is shared. This used to be called ‘sensitive’ data, and includes information about ethnicity, health, sex life or sexual orientation. This protection also applies to information concerning criminal offences. Information may be shared without consent if it is needed on the grounds of substantial public interest, which includes processing for the purposes of preventing or detecting unlawful acts, or safeguarding of children and vulnerable adults. You must have policies in place which govern information sharing with MARAC for either of these reasons.
Compliancy
It is the responsibility of the referring agency to comply with GDPR and the six key principles. Compliance with the spirit of these key principles is a fundamental building block for good data protection practice. It is also key to your compliance with the detailed provisions of the GPDR. Failure to comply with the principles may leave you open to substantial fines and criminal prosecution.
Purpose
The purpose of the MARAC Referral Form is to provide only the relevant information required to enable the MARAC Administrative team to process the personal data and information necessary to assess the threshold of the referral and populate an accurate MARAC agenda. This will then be sent to the relevant agencies listed within the MARAC Terms of Reference, as agreed within the West Midlands MARAC Operating Protocol. 
It is the responsibility of the referring agency to be satisfied that the threshold for MARAC is reached (that the victim of domestic abuse is at high risk of serious harm or homicide) before referring; this threshold will also be reviewed by the MARAC team. 
Consent
The GDPR sets a high standard for consent. However, when a person is assessed to be at high risk of serious harm or homicide (meeting the MARAC threshold) information can be shared without consent and the client cannot choose to withdraw from the process. In many circumstances, it would increase the risk of the victim suffering further harm if consent were sought or given. If safe, consent may still be sought by the practitioner, however even if consent is not obtained, this referral should still be made.
CONSIDERATIONS FOR REFERRAL	
PRIMARY REASON FOR REFERRAL*		
HAS A SEPARATE REFERRAL BEEN MADE FOR IDVA SUPPORT?	YES  NO 	IF YES, PLEASE PROVIDE DETAILS	IDVA SERVICE	DATE REFERRED	
			     	     	
IS THE VICTIM AWARE OF THIS REFERRAL, AND OF YOUR CONCERNS? *	YES  NO 	IF NO, PLEASE EXPLAIN WHY NOT	     	
HAS CONSENT BEEN OBTAINED TO MAKE THIS REFERRAL? *	YES  NO 	
PLEASE CONFIRM THE LAWFUL BASIS FOR THE PROCESSING OF THIS PERSONAL INFORMATION * (see GDPR guidance on page 1)		
I, THE REFERRER, CAN CONFIRM THAT WHERE ANY SPECIAL CATEGORY DATA IS SHARED WITHIN THIS REFERRAL FORM, IT IS DONE SO LAWFULLY UNDER SECTION 9(2)(g) OF THE GDPR: PROCESSING IS NECESSARY ON THE GROUNDS OF SUBSTANTIAL PUBLIC INTEREST. CRIMINAL OFFENCE DATA IS SHARED LAWFULLY UNDER SECTION 10 OF GDPR	
YES  NO 	

REFERRER INFORMATION	
DATE OF REFERRAL	     	LAST MARAC DATE
(IF REPEAT REFERRAL)	     	
MARAC LOCALITY 		
REFERRING AGENCY *	     	
NAME OF REFERRER *	     	
POSITION / JOB TITLE *	     	
REFERRER CONTACT NUMBER *	     	
REFERRER EMAIL *	     	

RISK ASSESSMENT	
HAS A RISK ASSESSMENT BEEN COMPLETED? *	YES  NO 	
	WHAT WAS THE SCORE?	     	
	WHERE A RISK ASSESSMENT HAS NOT BEEN COMPLETED, PLEASE EXPLAIN WHY THIS WAS NOT POSSIBLE	     	

VICTIM DETAILS	
NAME *
(include all known alias’)	     	DATE OF BIRTH *	     	
CONTACT NUMBER	     	IS NUMBER SAFE	YES  NO  
UNKNOWN  	
ALTERNATIVE KNOWN SAFE CONTACT NAME I.E PARENT, FRIEND	     	ALTERNATIVE SAFE CONTACT NUMBER	     	
USUAL HOME ADDRESS *	     	GENDER *	     	
		LANGUAGE SPOKEN	     	
		ETHNICITY *	     	
CURRENT ADDRESS
(if different from above)	     	DISABILITY *	     	
		LGBT RELATIONSHIP	YES  NO 	
		GP SURGERY	     	
OTHER RELEVANT INFORMATION REGARDING MENTAL HEALTH, SUBSTANCE MISUSE OR OTHER SIGNIFICANT ADDITIONAL NEEDS OF THE VICTIM	     	

PERPETRATOR DETAILS	
NAME *
(include all known alias’)	     	DATE OF BIRTH *	     	
RELATIONSHIP TO VICTIM *	     	GENDER *	     	
USUAL HOME ADDRESS *	     	ETHNICITY	     	
CURRENT ADDRESS 
(if different from above)	     	DISABILITY	     	

CHILD DETAILS	
NAME *	DOB *	RELATIONSHIP TO	LIVING WITH	
		VICTIM	PERPETRATOR		
     	     	     	     	     	
     	     	     	     	     	
     	     	     	     	     	
     	     	     	     	     	
     	     	     	     	     	
     	     	     	     	     	
     	     	     	     	     	
     	     	     	     	     	
     	     	     	     	     	

REASONS FOR REFERRAL	
BRIEFLY EXPLAIN YOUR GROUNDS FOR REFERRAL, I.E YOUR PROFESSIONAL JUDGEMENT OF THE RISK OF DOMESTIC ABUSE *	     	
PROVIDE DETAILS OF THE MOST RECENT INCIDENT(S) *	     	
PROVIDE A BRIEF HISTORY OF THE RELATIONSHIP BETWEEN THE VICTIM AND THE OFFENDER *	     	
DETAILS OF SUPPORT AND SAFEGUARDING ALREADY IN PLACE *	     	
PROVIDE DETAILS OF THE SUPPORT AND SAFEGUARDING REQUIRED 
FROM MARAC *	     	
HAS THIS INCIDENT BEEN REPORTED TO THE POLICE EITHER BY THE VICTIM OR THE REFERRING AGENCY? 
IF NOT, PLEASE PROVIDE THE REASON. *	     	

RISKS AND TRIGGERS 	
RISKS TO VICTIM	RISKS TO CHILDREN	OFFENDER TRIGGERS	

 Physical 	
 Physical 	
 Alcohol 	
 Emotional 	 Emotional 	 Drugs 	
 Threats 	 Threats 	 Child Contact 	
 Intimidation 	 Intimidation 	 Controlling Behaviours 	
 Sexual 	 Sexual 	 Jealousy 	
 Isolation 	 Isolation 	 Mental Health 	
		 Bereavement 	
		 Loss of Employment	

POLICE INVOLVEMENT
to be completed by Police Safeguarding Team only	
POLICE CRIME REFERENCE NUMBER	     	SAFEGUARDING OFFICER	     	
CURRENT OFFENCE	     	
SIG MARKER ON ADDRESS	YES  NO 	NON-MOLESTATION OR RESTRAINING ORDER	NON-MOL  RO  	
OFFENDER CURRENT DISPOSAL	CHARGED  REMANDED  POLICE BAIL  COURT BAIL  CAUTION  

COMMUNITY RESOLUTION  DVPO/DVPN  NFA 	
BAIL CONDITIONS	     	
PNC MARKERS	     	
OPEN TO DOMESTIC ABUSE OFFENDER MANAGERS	YES  NO 	
CHARGES, COURT DATE, SENTENCING SUMMARY	     	
POLICE HISTORY AND SAFEGUARDING SUMMARY