Pause Derbyshire Referral Form

Pause Derbyshire works with women who have experienced or are at risk of repeated pregnancies that result in children needing to be removed from their care.

Before completing this form, please ensure that the person you are referring meets the following criteria:

- The woman must be a resident of Derby City

- Two or more children have been removed from their care and they are at risk of further
pregnancies

- The woman must be under 40 years of age

- The woman must have no children in their care and they must not currently be pregnant

- The woman must have expressed explicit consent to this referral. If the woman you wish to
refer meets the above criteria, please fill in the form providing as much information as
possible.

Referrer’s details:

Woman’s details:

Children’s details

Children’s details (2)
Children’s details (3)
Children’s details (4)
Children’s details (5)

Other professional involvement

Role / Agency (2)
Role / Agency (3)
Role / Agency (4)
Role / Agency (5)

Presenting needs checklist

Mental health
Domestic abuse
Homelessness:
Sex work (sell/exchange)
Criminal justice issues
Substance misuse
Learning difficulty:
Physical health problems:
Other
Care leaver
Additional information

Please provide any further details you have, including any relevant risk information

Consent

Data Protection Policy

Our Data Protection Policy:
The information that you have given us will be used and stored by us in line with the data protection legislation. Great care is taken to ensure that personal information cannot be accessed by unauthorised personnel and that the Data Protection (GDPR) principles are adhered to.

Your information will be used or held in the following ways:

As referral details for the Pause programme

For the purpose of monitoring and evaluation we may share some of the information with partner organisations and those who provide the funding for our programme. Great care is taken to ensure that individuals cannot be identified and only numbers are passed onto these organisations. Without mentioning your name, the information we collect helps to give feedback to these organisations about who is benefitting from our training programme and about volunteering opportunities.