ISVA Adult Needs and Risk Assessment

Confidential Adult Needs & Risk Assessment
Please complete this form, answering as many questions as you feel able to. Then click submit.

The information you provide is extremely helpful and will ensure you receive the most appropriate support from an ISVA. The information you provide is confidential and will not be passed on to other agencies (see Data Protection Statement at bottom of this form).

Only answer the questions you feel comfortable answering.

If you have any questions, or need help completing this form, contact us on 0114 241 2766, and a member of the ISVA team will support you to complete it.

If you do not complete this form and agree to the Data Protection statement, we will not hold your contact details and your personal information will be deleted from our system, but we will be unable to offer you support.
Client first name First Name Client number (Your client number is in the email you received asking you to complete this form).
What pronoun would you like us to use for you? You don't have to answer this, but it will help us address you as you wish to be addressed.
MrMrsMissMsDrOther
If you have answered other, please give details.
Have you used this service before?
YesNoUnsure
Police information
Yes No
Have you reported to the police?
Are you thinking of reporting to Police?
Have you decided not to report to the Police?
If police are involved who is the OIC (officer in charge)?
Personal Details
MaleFemaleTransgender femaleTransgender maleNon-binaryOther
What is your ethnicity?
What is your religion?
What is your sexuality?
Is it safe to text/leave voicemails?
YesNo
What is the safest and preferred method to contact you?
PostPhoneTextWhatsAppEmail
Please provide details of your GP
NameName of surgery/practice
GP Telephone Number
Is your GP aware of the abuse?
If you have answered no, would you like your GP to be informed?
Please provide an emergency contact below
Name
Are you currently pregnant?
If you are pregnant, please provide your due date
MonthDayYear
Date
If you have children please provide details of them below
Name of child Child's date of birth Do you have parental responsibility for this child? Y/N School child attends Does this child live with you? Y/N
Child 1
Child 2
Child 3
Child 4
Child 5
Are there any support services involved with you or your children (including social care)?
If support services are involved, please provide details below
Name and contact address Telephone Number Number Agency
Fist Agency
Second Agency
Third Agency
Type a question
Name of School/College/University Telephone Number Name of staff contact
Primary School/college
Any other school/college
Health and Wellbeing Questions
Do you suffer from anxiety?
CurrentlyPreviouslyNever
Do you feel depressed?
CurrentlyPreviouslyNever
Do you have thoughts of self harm?
CurrentlyPreviouslyNever
Have you ever self-harmed?
CurrentlyPreviouslyNever
Have you misused drugs or alcohol?
CurrentlyPreviouslyNever
Have you ever had suicidal thoughts?
CurrentlyPreviouslyNever
Have you ever attempted suicide?
RecentlyPreviouslyNever
If you have any other mental health diagnosis, please provide details here.
Do you have a disability?
Do you have any learning difficulties?
Please provide details of your learning disability below
If you have any other difficulties that you would like us to be aware of, please provide details below.
Do you have any sexual health concerns/needs?
Please include information about any GUM referrals
Relationships
Are you currently in a relationship?
Has there ever been any domestic violence in your current relationship?
If you have answered yes to the above, do you receive support from the IDVA service?
Have you ever been referred to MARAC?
Finances
Do you have any financial difficulties or pressures?
If you have answered yes, please provide details below.
Employment
Are you currently employed?
If you are employed, is it full-time or part-time employment?
Housing
Is your housing secure and safe?
If you have answered no to question above, please provide further details below.
Perpetrator details (the person or people who have harmed or tried to harm you)
In order for us to offer you the correct support please provide details below
Number of perpetrators
Did you know your perpetrator/s?
How do you know the perpetrator/s
Has the perpetrator/s been ...
ArrestedChargedAwaiting trial
Time lapse since the abuse happened to you
In order for us to offer you the correct support please tick the most appropriate box
When did the abuse happen?
Less than a year agoMore than a year agoI am an adult now and the abuse took place when I was under the age of 18 years
Abuse Information
In order for us to offer you the correct support please chose the option which most relates to your experience
Please tick all that apply
RapeAttempted RapeSexual AssaultGroomingRevenge Porn (sharing images of you)
Personal Circumstances
Please tick the options which most relates to your experiences and give details which will help us to give you the best support for your circumstances
Are you a Refugee/Asylum seeker?
If you have answered yes to the above question, please provide further details.
Have you experienced Human Trafficking?
If you have answered yes to the above question, please provide further details.
Are you currently a street worker?
Is English NOT your first language?
Do you require an interpreter?
Please provide any other information that may help us to support you.
Data Protection
This data protection statement sets out how we will use your personal data. SRASAC will collect your personal data (which includes sensitive personal data) and process your personal data for the purposes of providing you with support. The personal data collected on this form will be kept secure and confidential within SRASAC. Your personal data will only be used as necessary for our legitimate interests in order to provide you with support and monitoring within SRASAC. This information will never be disclosed to any external sources without your express written consent. SRASAC does share anonymised and unidentifiable information with funders in support of our work.
By ticking the box below you are giving SRASAC your consent to hold the information given on this form about you. Where consent has been given you are free, at any time, to change your mind and withdraw your consent by contacting us at info@srasac.org.uk
Where consent has been withdrawn SRASAC will delete any personal information we have stored. SRASAC will retain your personal data only for as long as is necessary for the provision of support. This statement is in accordance with the General Protection Regulation (GDPR) (EU) 2016/679.
Please tick to agree to the statement above.
I agree
Signature
Clear
If you are completing this form on behalf of someone, please give your details below.
First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Signature (please sign here if you are completing the form for someone.
Clear
Should be Empty:

	Yes	No
Have you reported to the police?
Are you thinking of reporting to Police?
Have you decided not to report to the Police?

	Name of child	Child's date of birth	Do you have parental responsibility for this child? Y/N	School child attends	Does this child live with you? Y/N
Child 1
Child 2
Child 3
Child 4
Child 5

	Name and contact address	Telephone Number Number	Agency
Fist Agency
Second Agency
Third Agency

	Name of School/College/University	Telephone Number	Name of staff contact
Primary School/college
Any other school/college

Confidential Adult Needs & Risk Assessment

Health and Wellbeing Questions

Relationships

Finances

Employment

Housing

Perpetrator details (the person or people who have harmed or tried to harm you)

Time lapse since the abuse happened to you

Abuse Information

Personal Circumstances

Data Protection