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Together Community Liaison and Diversion Service Referrals

Together Community Liaison and Diversion Service Referrals

On this page referrals can be made to Together's Community Liaison and Diversion Service either by professionals on behalf of an individual or people referring themselves.

Together’s Community Liaison and Diversion Service operates Pan London and comprises of Community Link Workers and Peer Support Volunteers. Please fill in the form below to make a referral and the team will be in touch soon. If you have any issues completing the form please contact comms-admin@together-uk.org.

Together Community Liaison and Diversion Referral Form

Community Liaison & Diversion Team Referral Form

Who is making the referral to Together's Community Liaison and Diversion Service?

Who is making the referral to Together's *

I'm a person referring myself

I'm a professional referring someone

Do you live in London? *

Yes

Please note: The Community Liaison and Diversion service is only available to people who live in London. If the answer to the question above is no, please don't complete the rest of the form as the team won't be able to support you.

Self-referral

What part of the service would you like to access? (Tick one) *

Emotional Support (Peer Support)

Community Link Workers

Both

I'm unsure

First Name *

Surname *

Date of birth *

Please use date format DD/MM/YYYY

Which of the following best matches the way you describe your ethnicity?

White - English / Welsh / Scottish / Northern Irish / British

White - Irish

White - Gypsy or Irish Traveller

White - Any other white background

Mixed / multiple ethnic groups - White and Black Caribbean

Mixed / multiple ethnic groups - White and Black African

Mixed / multiple ethnic groups - White and Asian

Mixed / multiple ethnic groups - Any other

Mixed / multiple ethnic background

Asian / Asian British - Indian

Asian / Asian British - Pakistani

Asian / Asian British - Bangladeshi

Asian / Asian British - Chinese

Asian / Asian British - Any other Asian background

Black / African / Caribbean / Black British - African

Black / African / Caribbean / Black British - Caribbean

Black / African / Caribbean / Black British - Any other Black / African / Caribbean background

Other ethnic group - Arab

Other ethnic group - Any other ethnic group

Do not wish to answer

Address *

Borough *

Postcode *

Phone Number *

Email Address (if you don't have an email just put "N/A") *

Methods you do not want us to contact you on: Please Tick:

Voicemail/Text

Letters/Post

Please provide information about your support needs: *

Have you been in contact with a court of police station in the last 3 months? *

Yes

If the answer above was yes please provide more information and the date:

Address of court/police station:

Date last seen (if known):

Do you consent for us to contact them for more information:

Yes

Self-referral links with external services (Contact Details)

Do you have existing links with a GP?

Yes

Please provide contact details:

Do you have existing links with probation?

Yes

Please provide contact details:

Do you have existing links with Multi-agency public protection arrangements (MAPPA)?

Yes

Please provide contact details:

Do you have existing links with Drug & Alcohol Workers?

Yes

Please provide contact details:

Do you have existing links with community mental health teams?

Yes

Please provide contact details:

Do you have existing links with keyworkers?

Yes

Please provide contact details:

Do you have existing links with safeguarding teams?

Yes

Please provide contact details:

Do you have existing links with any additional services?

Yes

Please detail those additional services and provide contact details:

Do you have issues with a drug or alcohol dependency?

Yes

Please provide further details:

Please use the space below to share any other additional information you feel we should be aware of:

Professional referring a person

What part of the service would the person like to access?

Peer Support

Community Link Workers

Both

Unsure

Referee's first name *

Referee's surname *

Referee's date of birth *

Please use date format DD/MM/YYYY

Referee's Address *

Referee's Borough *

Referee's postcode *

Referee's Phone *

Referee's Email (if the referee doesn't have an email just add "N/A") *

Which of the following best matches the way the person you're referring describes their ethnicity? *

White - English / Welsh / Scottish / Northern Irish / British

White - Irish

White - Gypsy or Irish Traveller

White - Any other white background

Mixed / multiple ethnic groups - White and Black Caribbean

Mixed / multiple ethnic groups - White and Black African

Mixed / multiple ethnic groups - White and Asian

Mixed / multiple ethnic groups - Any other

Mixed / multiple ethnic background

Asian / Asian British - Indian

Asian / Asian British - Pakistani

Asian / Asian British - Bangladeshi

Asian / Asian British - Chinese

Asian / Asian British - Any other Asian background

Black / African / Caribbean / Black British - African

Black / African / Caribbean / Black British - Caribbean

Black / African / Caribbean / Black British - Any other Black / African / Caribbean background

Other ethnic group - Arab

Other ethnic group - Any other ethnic group

The person does not wish to answer

Unknown

Your first name *

Your surname *

Organisation you work for: *

Other details:

Your phone *

Your email *

Please mark any methods of contact which are not suitable for correspondence with the person being referred:

Voicemail/Text

Letters/Post

Index Offence: *

(Include outcome if known)

Date due back in court:

(If applicable)

Do you have details of the referee's offending history? *

Yes

Unknown

Please provide further details the referee's offending history

(if applicable)

Priority reason(s) for referral and additional information:

Reason 1 for referral - provide details *

Reason 2 for referral - provide details

Reason 3 for referral - provide details

Does the person you're referring have links with external services?

Yes

Please provide contact details:

Do you have existing links with a GP?

Yes

Please provide contact details:

Do you have existing links with probation?

Yes

Please provide contact details:

Do you have existing links with Multi-agency public protection arrangements (MAPPA)?

Yes

Please provide contact details:

Do you have existing links with Drug & Alcohol Workers?

Yes

Please provide contact details:

Do you have existing links with community mental health teams?

Yes

Please provide contact details:

Do you have existing links with keyworkers?

Yes

Please provide contact details:

Do you have existing links with safeguarding teams?

Yes

Please provide contact details:

Do you have existing links with any additional services?

Yes

Please detail those additional services and provide contact details:

Risk and Need Information

Do you have a risk assessment or any other documentation relating to the person you are referring and their lived experience?

Yes

If you don't have any documentation related to risk and the person's lived experience it may be better for the person to do a self-referral with support from you. If however, that would mean a significant delay in the referral please do just carry on and complete the form as a professional.

Please attach risk assessment document from your organisation

Maximum file size: 52.43MB

If you have any issues uploading documents please email those to community.liaisonanddiversion@nhs.net directly. If there are specific issues with the form here you can let us know at comms-admin@together-uk.org and we'll look to fix those.

Does the person pose a risk to themselves (e.g. self-harm, current or recent suicidal ideation): *

Currently

Previously

Please provide details (if you don't know the details please just answer 'Unknown'):

Does the person pose a risk to others (e.g. family, friends, strangers, police officers, females): *

Currently

Previously

Please provide details (if you don't know the details please just answer 'Unknown')::

Is the person posed a risk by others (e.g. gang affiliation, exploitation, human trafficking): *

Currently

Previously

Please provide details (if you don't know the details please just answer 'Unknown')::

Are there any further risks posed to the person? (physical health, risk to staff, sexual offences, stalking offences, terrorism): *

Currently

Previously

Please provide details (if you don't know the details please just answer 'Unknown')::

Has there been a safeguarding referral made for the person? *

Yes

Safeguarding Agency (if you don't know the details please just answer 'Unknown')::

Date of referral (if you don't know the details please just answer 'Unknown')::

Safeguarding agency address:

Safeguarding agency phone number:

Safeguarding agency email:

Does the person have issues with a drug or alcohol dependency? (e.g. current or previous misuse, what type of drug, amount and frequency, previous IV use, BBV, dependency or binge drinking etc.) *

Yes

How does their behaviour/presentation change when under the influence? (if you don't know the details please just answer 'Unknown'):

Please use this space to share any further information to support referral:

If there are other documents you could attach to assist with the referral like a consent form, L&D/NHSE report, external agency report or risk assessments please attach those here:

Maximum file size: 52.43MB

Please tick the box below to show that you or the person you’re referring agree to provide consent to share this information with Together’s Community Liaison and Diversion Team and to be contacted by us. Together will only use this information to look to provide mental health support through the service and that can include sharing this with other agencies related to your query like health or social care services to coordinate that response. Information will not be shared with any other third parties. Together's privacy policy is at https://www.together-uk.org/privacy-notice/ *

I agree

If you are human, leave this field blank.

What would you like to find?

Looking for something specific?

I’m a commissioner and I want to see what services you provide

I’m a social worker or care coordinator and I want to find a service near my client

I’ve been referred to one of your services and would like to learn more about you

Together Community Liaison and Diversion Service Referrals

Together Community Liaison and Diversion Referral Form

Who is making the referral to Together's Community Liaison and Diversion Service?

Please note: The Community Liaison and Diversion service is only available to people who live in London. If the answer to the question above is no, please don't complete the rest of the form as the team won't be able to support you.

Self-referral

Self-referral links with external services (Contact Details)

Professional referring a person

Priority reason(s) for referral and additional information:

Risk and Need Information

Together Community Liaison and Diversion Service Referrals

Together Community Liaison and Diversion Referral Form

Who is making the referral to Together's Community Liaison and Diversion Service?

Please note: The Community Liaison and Diversion service is only available to people who live in London. If the answer to the question above is no, please don't complete the rest of the form as the team won't be able to support you.

Self-referral

Self-referral links with external services (Contact Details)

Professional referring a person

Priority reason(s) for referral and additional information:

Risk and Need Information

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