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Domestic Violence Services
Referral form
Gender
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Male
Female
Prefer not to say
Age
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Under 16
16 - 18
19 - 25
26 - 30
31 - 60
60+
Ethnicity
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White
English, Welsh, Scottish, Northern Irish or British
Irish
White and Black Caribbean
White and Black African
White and Asian
Any other Mixed or Multiple ethnic background
Asian or Asian British
Indian
Pakistani
Bangladeshi
Chinese
Any other Asian background
African
Caribbean
Any other Black, African or Caribbean background
Arab
Any other ethnic group
Contact details
Phone number
Are You Happy For An Emotional Support Volunteer To Leave A Voicemail/Message At Any Time?
Select
Yes
No
Preferred Time For Contact:
Select
08:00 - 12:00
12:00 - 17:00
17:00 - 21:00
Anytime between 08:00 - 21:00
Clients Preferred Language:
I Would Like Support/Counselling For:
Depression and Anxiety
Bereavement
End - of - life care
Domestic Violence
Addiction/Alcohol rehabilitation
Other: Please specify
Medical/Mental Health History:(please provide as much detail as possible)
Drug History: (please include prescribed drugs and any other drugs)
Name of the GP
GP Surgery/Practice
Address
Contact number
Thank you for taking the time to complete this form.
All referral forms are screened and referred to the appropriate team. The support you're offered will depend on the problems you're experiencing and how severe they are. Someone from the Supporting Humanity team will get in touch to ask about the problems you're having.
This service does not provide assistance or support if you need urgent help in a crisis, If you or a loved one are experiencing a mental health crisis, please call a local NHS mental health helpline for 24-hour advice and support by finding your local service by following the link below:
https://www.nhs.uk/service-search/mental-health/find-an-urgent-mental-health-helpline
or If someone's life is at risk or they cannot be kept safe, call 999 or go to A&E.