Referral: Family Assessment Support Homicide (F.A.S.H)

The HUB provides peer support and practical advice for families affected by homicide and culpable road deaths. Through this assessment form, we aim to identify concerns and any additional needs so we can offer tailored support to family members.

The F.A.S.H form helps us gather essential information of their circumstances, ensuring we can provide the most relevant and effective assistance.

Once you provide the information of the person you are referring, we’ll listen to their needs and provide the help that’s most relevant to them and their family members.

No one should have to suffer in silence.

1: About You & Your Organisation

Organisation Name

Organisation Address

Number & Street Address City County Postcode Country

Organisation Phone Number

Organisation Email Address

Your Name

First Name Surname

Signature

By signing, you confirm you have permission from the person you are referring.

Todays Date

2: About the Incident

In order to offer the appropriate support, we need some basic information about the incident. Please provide the name of the victim and the date of the incident.

Victim’s Name

Date of Incident

3: Situation Information

To better understand the needs of the individual, we ask that you provide details about the circumstances that have led to The HUB’s involvement. This information will help us identify areas that require support, prioritise urgent concerns, and determine if external referrals are necessary.

Please provide details of the areas in need of support

This includes areas of concern to monitor, areas of priority, and needs that may require external referral.

4: Personal Details of the Person you are Referring

In this section, we ask for personal details of the individual of the person you are referring. This helps us when contacting them and ensures we understand their circumstances. Please note that the last two questions regarding sexual orientation and ethnicity are entirely optional, and you may choose not to answer them.

Name

First Name Surname

Gender

Male

Female

Other

Prefer Not To Say

Do they have a disability?

Yes

Disability Details

Please provide details of the disability:

Address & Contact Details

Please provide the address of the individual you are referring.

Address

Number & Street Address City County Postcode Country

Landline Telephone

Mobile Telephone

Email Address(Required)

We require the email address of the individual you are referring. Once you submit the details you provide, the individual you are referring will receive a notification to confirm the all information and details are correct.

Optional Questions

You do not have to answer the following questions if you do not wish to.

Sexual Orientation

Ethnicity

Please select the option that best describes your ethnic group or background

Asian or Asian British

Black, African, Caribbean, or Black British

Mixed or Multiple Ethnic Groups

Other Ethnic Group

White

Prefer Not To Say

5: OLLY Children’s Group

Do you know if any children connected to the individual you are referring would like to become a member of the O.L.L.Y Group (Our Lost Love Years)? If so, please provide the following information for each child. You can add more children by pressing the “ + ” icon. Please note: you will be required to complete a separate O.L.L.Y enrolment form for each child.

Childs Details

Child’s Name

Relationship to referred

Date of Birth

School/College

6: Affected Areas In Need Of Support

Please select any areas of support. These can include issues affecting mental health, physical wellbeing, or environmental circumstances. Identifying these areas will help us provide the most appropriate guidance and assistance.

Please tick all that apply

Any Extra Details?

Other Factors

Please specify any environmental factors that may require support.

7: Brief Outline of Your Tragedy Incident/Incidents

Please provide a brief outline of the incident or incidents. This information will help us better understand the circumstances and provide appropriate support.

Details

Please provide a brief outline of the incident or incidents.

Postcode of the cemetery where the victim has been laid to rest

Do you know which services may be able to provide the support you need?

Yes

Please provide details

Has the family of the individual you are referring, agreed to accept support and participate in the F.A.S.H Assessment?

Yes

8: Agree and Consent

Once you have read this form, please sign below to agree to its terms and confirm your consent for The HUB to provide support, or to refer you to the appropriate agency qualified in their field. The HUB will monitor your journey, including peer support, to ensure you receive the best assistance possible. If needed, with your consent, we may refer you to other specialised organisations.

Member’s Signature

Today’s Date

For Admin Use Only

Assessor’s Signature

Assessor’s Name

First Name Surname

Today’s Date

The HUB is a ‘One Stop Shop’, open five days a week from 9.30am to 4pm. No appointments are necessary.

Visit our main website for further information.