Refer yourself

Please complete this form if you want to access support. This form will be sent to IDAS securely and your information will be held confidentially.

Do you need emergency accommodation or support in your own home?*

Emergency accommodation

Support in your own home

Please contact your local helpline on 03000 110110 (North Yorkshire / Barnsley) or Housing Solutions 0114 273 6306 (Sheffield) or the 24-hour national domestic abuse helpline on 0800 2000 247

IDAS provide support through the family court in Doncaster. For all other support please ring: 01302 737080

Your name*

First

Last

Your phone number*

Is it safe to phone you?*

Yes

Is it safe to leave a message?*

Yes

What days and times is it best for us to contact you?*

Please enter days and times below

Your email address*

Is it safe to contact you via email?*

Yes

Other safe contacts

e.g. a friend or family member's phone number

Address line 1

Address line 2

City

Postcode

Your date of birth*

Do you have any children who are still dependent on you?*

Can you tell us what has been happening for you and what type of support you and /or your children need?

What is your relationship with the person who is or has been abusive to you?

Please tell us the name of the person who abused you if you know this.

Are the police or any other agencies involved? (Please give details)*

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

Please only tick 'yes' if you are sure your email is safe.

Yes

Are you human?*

Refer yourself to IDAS

If you refer yourself for support, we will direct your referral form to the appropriate service and someone will contact you as soon as possible. You can also phone our helplines for more immediate support. All our support is free of charge.

Referral form

IDAS

What we do

Get in touch

Helplines:

03000 110 110 - Barnsley and North Yorkshire

0808 2000 247 - Sheffield