Make a Referral

MAKING A REFERRAL TO OUR SERVICES

By completing this referral form, you’re helping us to make contact with the client as safely and quickly as possible.  We’d appreciate it if you could include as much information as possible – this saves the client from being asked the same questions twice and helps us to understand more about their particular needs and circumstances. If this referral is being done through a local church leadership, it must also be supported by the victims GP and/or social worker.

Referrer's Details
Details of the person making the referral
Referrer Name *
Referrer Email Address *
Referrer Phone Number
Relationship to Victim
e.g. GP, Social Worker, Church Leader
Referrer Job Title
e.g. GP, Social Worker
Has the person you are referring consented to being contacted by us? *
(Please note we can only contact clients with their permission. If you feel this case is high risk please refer to MARAC)
Please complete all required fields before continuing.
Victim's Details
Details of the Victim
Victim Name *
Victim Date of Birth
Phone Number
Email Address
Victim Address
Victim Postcode
Housing Situation
Any connections to the area?
Are they rough sleeping?
Marital Status
Gender
Ethnicity
Religion
First Language
Is an interpreter required?
Do they have access to external funds?
Immigration Status
Employment Status
Income
Education
Disabilities & Accessibility Requirements
Please check all required fields are completed to continue.
Victim's History
Any history of Self Harm?
Has this person attempted suicide?
If yes, please confirm date of last attempt.
Any history of substance abuse?
Any Criminal Record or Convictions?
Please give details
Are they a care leaver?
Are they Service Personnel or part of the Armed Forces?
Please check all required fields are completed to continue.
Next of Kin
Next of Kin Name
Next of Kin Phone Number
Next of Kin Email
Please check all required fields are completed to continue.
Perpetrator Details
Perpetrator Name *
Perpetrator DOB
Perpetrator Current Address
Perpetrator Current Postcode
Any connection to the area?
Are the victim and perpetrator currently in a relationship?
Any history of substance abuse?
Disabilities
Any Criminal Record or Convictions?
Please give details
Please check all required fields are completed to continue.
Children
Does the victim have any children?
Children
Please check all required fields are completed to continue.
Referral Details
Please provide brief details about the types of Domestic Abuse experienced *
e.g. physical, emotional, sexual, financial etc.
Are there any known risks in working with this client?
If yes, please provide details
Has the client previously been in refuge?
If yes, please provide details of when, where and any reasons for leaving.
Please check all required fields are completed before continuing.
Other Agency Details
Details of other agencies involved
Please complete all required fields before continuing.
Are you interested in being signposted to other agencies who can offer you support?
Please tick all that apply