Referral Form About the referral Is this referral for yourself or for someone else? (required) Please Select.. Myself Someone else If this referral is for someone else please enter your own name, organisation, email address and phone number here Details of person being referred First name (required) Last name (required) Date of Birth Gender Please Select.. Female Male Intersex Gender queer Non binary Other Prefer not to answer Are you transgender? Please Select.. Yes No Don't know Prefer not to answer Address Country (required) Please Select.. United Kingdom Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia, Plurinational State of Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cabo Verde Cambodia Cameroon Canada Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, The Democratic Republic of the Cook Islands Costa Rica Croatia Cuba Curaçao Cyprus Czechia Côte d'Ivoire Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran, Islamic Republic of Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova, Republic of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Macedonia Northern Mariana Islands Norway Oman Pakistan Palau Palestine, State of Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Romania Russian Federation Rwanda Réunion Saint Barthélemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Sweden Switzerland Syrian Arab Republic Taiwan, Province of China Tajikistan Tanzania, United Republic of Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela, Bolivarian Republic of Viet Nam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Address Line 1 (required) Address Line 2 City / Town (required) County (required) Postcode (required) Contact details Phone Email address What are safe ways to contact you? (tick all that apply) Phone call Voicemail SMS/Text Email What is the best time to contact you? Alternative safe phone to use (if any) e.g. friend/family Abuse details What is the reason for the referral? Please provide as much information as you can to help us identify the best way to support you What kind of abuse are you currently experiencing? (tick all that apply) Emotional Abuse Physical Abuse Sexual Abuse Coercive Control Stalking Financial Abuse Technology Abuse Harassment What kind of support are you looking for? (tick all that apply) One to One Group Advocacy Other/Don't Know Perpetrator's Name (if known) Perpetrator Date of Birth Does perpetrator live at same address as you? Please Select.. Yes Sometimes No Perpetrator’s address (if different) Perpetrator Address Line 1 Perpetrator Address Line 2 Perpetrator City / Town Perpetrator Postcode Relationship to you (e.g. spouse, partner, ex-partner etc.) Length of relationship (if applicable) Your current relationship status Other details How many children do you have? Please Select.. None 1 2 3 4 5+ What are your children's ages (if applicable, separated by commas)? Are local authority children's services involved? Please Select.. Yes No What type of accommodation are you in? Please Select.. Accommodation provided by employer Approved Probation Hostel Bed and Breakfast Children's Home / Foster Care Foyer Home Office Asylum Support Hospital Hostel LA General Needs Living with Family / Friends Military Accommodation Mobile Home / Caravan Owner Occupier Prison Private Sector Residential Care Home Rough Sleeper RSL General Needs Sheltered Housing Social housing Sofa Surfing Student Accommodation Supported Housing Temporary Accommodation Women's Refuge Other Don't Know What is your employment status? Please Select.. Apprenticeship or Government Training Carer Employed Full Time Employed Part Time (less than 24 hours) Long Term Sick Leave or Disabled Maternity Leave Retired Self-employed Student Unemployed and not Seeking Work Unemployed and Seeking Work Decline To Answer Don't Know Other Do you have a support network (e.g. family and/or friends)? Please Select.. Yes No If other services are involved, please list them here Do you have a disability? Please Select.. Yes No If yes, please tick all that apply Physical Disability Learning Disability Hearing Disability Vision Disability Mental Health Disability Long Term Condition Speech Impairment Do you have additional needs? (tick all that apply) Pregnant Mental Health Support Physical Health Support Drug Support Alcohol Support Offending Support Are you self-harming? Please Select.. Yes No Do you have any suicidal thoughts? Please Select.. Yes No Have you attempted suicide? Please Select.. Yes No Please use this space to provide any additional information you want us to know Consent Do you wish your information to be shared ANONYMOUSLY with Women's Aid Federation of England to support domestic abuse research and campaigning? Nothing that could identify you or your children will ever be shared or made public as a result of this research. Please Select.. Yes No
