Make a referral

Any organisation or individual can make a referral. If you refer yourself for support, we will direct your referral form to the appropriate service and someone will contact you within 72 working hours.

All information is stored securely and we will treat your information as confidential and will not share it with any other agency unless we are required to do so by law, or unless any person will come to harm if we do not share it. If you are a professional referring a client, we may contact you for further information and to inform you of the referral outcome. All referrals are assessed and prioritised according to need and risk.

Referral form

Which service you are referring to?*

Your name*

First

Last

Your email address*

Your telephone number*

Agency you represent

Name of the person you are referring*

First

Last

Address of the person you are referring*

Address line 1

Address 2

City

Postcode

Date of birth of the person you are referring

Are there any dependent children? Please enter their names and ages below.

What are the safe contact details for the person you are referring?*

Is it safe to text?*

Yes

No

Don't know

Is it safe to leave a voicemail on the landline?*

Yes

No

Don't know

Is it safe to leave a voicemail on the mobile?*

Yes

No

Don't know

Does the person you are referring require an interpreter?*

Yes

No

Which language is required?

When is the best time to contact the person being referred?*

What is the reason for your referral?*

Please provide as much information as possible including the nature of abuse and the type of support required.

Relationship status of victim and abuser*

Name of alleged abuser

Are the police involved?*

Yes

No

Don't know

Police incident number

Has a DASH assessment been completed?*

Yes

No

Don't know

What is the level of risk?

Does the person consent to IDAS support?*

Yes

No

Would you like to receive an email confirming this referral?*

Yes

No

If you are referring yourself, only tick 'yes' if you are sure your email is safe.

Are you human?*

This field should be left blank

Make a referral

Any organisation or individual can make a referral. If you refer yourself for support, we will direct your referral form to the appropriate service and someone will contact you within 72 working hours.

Referral form

IDAS

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