Get me away
from this site!

Gloucestershire Domestic Abuse Support Service

01452 726 570 support@gdass.org.uk

Group work referral form

We cannot guarantee a place on the course until GDASS have reviewed all of the referrals to ensure that the group is suitable for all. If your client is not offered a place on the course we will discuss their options around support which may be more suitable to meeting their needs. Please be aware the referral cannot proceed if information on this form is not complete. If you have any questions, contact us on 01452 726570 or email support@gdass.org.uk.

Programmes

The Phoenix Programme – for women who are no longer experiencing domestic abuse.

Breathe – for women currently living with an abusive partner, and those who have left abusive partners.

Referrer

Details of the person making the referral:

Client

Details of the person being referred:

Alleged perpetrator

Details of the alleged perpetrator:

Children

Details about the client's first child:

Details about the client's second child:

Details about the client's third child:

Details about the client's fourth child:

Details about the client's fifth child:

Details about the client's Sixth child:

History

Details about the history of abuse: