Venture Trust takes our users security and privacy concerns seriously. All data submitted via this form is encrypted from end to end by SSL. It cannot be intercepted in transmission and once submitted to our secure system it will only be viewed by authorised staff via their unique passwords. Referrer details First Name * Last Name * Job Title Email * Phone Number * Street Address * City * Postal Code * Country * AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo, Republic of theCongo, The Democratic Republic of theCook IslandsCosta RicaCôte d’IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIran, Islamic Republic OfIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedonia, Republic OfMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States ofMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSerbia and MontenegroSeychellesSierra LeoneSingaporeSint Maarten (Dutch Part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwanTajikistanTanzania, United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Organisation Name * Organisation Phone Type of Referral Organisation - None -UnknownCourtsPartner AgencyPrison/YOISchools/Education Units/CollegeSelf-referralSocial WorkSocial housing / FoyersFair StartNHS Out of hours or Stand by phone Client's details Has the client worked with Venture Trust before? * Yes No Don't know First Name * Last Name * Phone Number Email Street Address * City * Local Authority * - Select -(Non Selected)Aberdeen CityAberdeenshireAngusArgyll and ButeClackmannanshireDumfries and GallowayDundee CityEast AyrshireEast DunbartonshireEast LothianEast RenfrewshireEdinburgh CityEilean Siar (Western Isles)FalkirkFifeGlasgow CityHighlandInverclydeMidlothianMorayNorth AyrshireNorth LanarkshireOrkney IslandsPerth & KinrossRenfrewshireScottish BordersShetland IslandsSouth AyrshireSouth LanarkshireStirlingWest DunbartonshireWest Lothian(Not Applicable)(Unknown) Postal Code * Country * AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo, Republic of theCongo, The Democratic Republic of theCook IslandsCosta RicaCôte d’IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIran, Islamic Republic OfIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedonia, Republic OfMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States ofMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSerbia and MontenegroSeychellesSierra LeoneSingaporeSint Maarten (Dutch Part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwanTajikistanTanzania, United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe National Insurance No. Birth Date Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year19201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020 Gender - None -FemaleMaleOther Reason For Referral * Candidates Situation Presenting Issues (Mark all that apply to the candidate) * Criminal Record? (If yes, fill out Criminal Justice section below) Previously Offended? (If yes, fill out Criminal Justice section below) Caring responsibilities Homeless or occupying unsettled or temporary accommodation History of substance abuse History of alcohol abuse Mental health issues Young person leaving care or is currently in care Armed Forces Veteran/Currently Serving (If yes, fill out Armed Forces section below) Registered Unemployed (Without work and in receipt of JSA) Not in education employment or training and aged 16 - 19 yrs Additional details (for any/all selected above) Does the client have any other Presenting Issues not listed above Yes No Other (details) Candidate's Justice Information SCRO Number Risk Assessment Framework Used Scoregrid 2 LowMediumHigh Risk To Community Risk To Community - Low Risk To Community - Medium Risk To Community - High Risk to Self Risk to Self - Low Risk to Self - Medium Risk to Self - High Scoregrid 3 YesNo Is candidate subject to a Probation Order? Is candidate subject to a Probation Order? - Yes Is candidate subject to a Probation Order? - No Is candidate subject to a Community Payback Order? Is candidate subject to a Community Payback Order? - Yes Is candidate subject to a Community Payback Order? - No Is candidate subject to a DTTO Order? Is candidate subject to a DTTO Order? - Yes Is candidate subject to a DTTO Order? - No Is the Candidate subject to any other orders? Is the Candidate subject to any other orders? - Yes Is the Candidate subject to any other orders? - No Is the candidate subject to any other orders (If yes please state which orders)? Please give the following details concerning the client's Court Orders selected above Main Offence Type of Offence Date of sentence Length of sentence Court sentenced at Type of court Civilian Court Military Court Scoregrid 4 YesNo Is attendance on a Venture Trust programme a condition of court/probation order/ CPO? Is attendance on a Venture Trust programme a condition of court/probation order/ CPO? - Yes Is attendance on a Venture Trust programme a condition of court/probation order/ CPO? - No Are there any outstanding charges, court causes or warrants? Are there any outstanding charges, court causes or warrants? - Yes Are there any outstanding charges, court causes or warrants? - No Is the candidate subject to any restrictions of liberty? Is the candidate subject to any restrictions of liberty? - Yes Is the candidate subject to any restrictions of liberty? - No IF yes for Is attendance on a Venture Trust programme a condition of court/probation order/ CPO, please give details: If yes for Are there any outstanding charges, court causes or warrants, please give details: If yes for is the candidate subject to any restrictions of liberty, please give details: Court/Case Reference Number Assessment report due Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year19701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025202620272028202920302031203220332034203520362037203820392040204120422043204420452046204720482049205020512052205320542055205620572058205920602061206220632064206520662067206820692070 Does the candidate have convictions for any of the following: Scoregrid YesNo Sexual Offences Sexual Offences - Yes Sexual Offences - No Fire Setting Fire Setting - Yes Fire Setting - No Racially Aggravated Offence Racially Aggravated Offence - Yes Racially Aggravated Offence - No Recent Serious Violence Recent Serious Violence - Yes Recent Serious Violence - No If yes to Sexual Offences, please provide details below If yes to Fire Setting, please provide details below If yes to Racially Aggravated Offence, please provide details below If yes to recent serious violence, please provide details below If yes to the above, please upload any relevant documentation here. Files must be less than 2 MB.Allowed file types: gif jpg jpeg png txt rtf html pdf doc docx odt ppt pptx odp xls xlsx ods xml. Is the candidate subject to any legal orders that would exclude them from obtaining certain jobs or working with certain people? Yes No Please give details of legal order(s) here Please upload any relevant documentation regarding legal orders here. Files must be less than 2 MB.Allowed file types: gif jpg jpeg png txt rtf html pdf doc docx odt ppt pptx odp xls xlsx ods xml. General Background Information General Background Information (files) Files must be less than 2 MB.Allowed file types: gif jpg jpeg png txt rtf html pdf doc docx odt ppt pptx odp xls xlsx ods xml. Candidate's Armed Forces Information (Client info) Currently serving or Veteran Currently Serving Veteran Service Number Armed Service British Army Royal Navy Royal Air Force Branch/Regiment Regular or Reservist Regular Reservist Basic Training Location Basic Training Completed Yes No Length of service Rank Attained Have any post-service support been accessed e.g for housing, employment, medical issues? Yes No Is this post-service support still ongoing? Yes No If yes, please provide further information Date of discharge Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year19701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025202620272028202920302031203220332034203520362037203820392040204120422043204420452046204720482049205020512052205320542055205620572058205920602061206220632064206520662067206820692070 Reason for discharge - None -End of contractDischarge of noticeDischarge medicalDischarge Service No Longer Required Discharge of notice Discharge medical Discharge Service No Longer Required Referral Date Referral Date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20182019202020212022
