Group work self-referral

Programme

Which programme are you referring your client to?

Six Steps to Domestic Abuse Insight – for men and women who are no longer experiencing domestic abuse.

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

Name

Date of birth

Date

Address

Telephone number

Email address

Ethnicity

Gender

First language

Name

Date of birth

Date

Address

Your children

Are you still in a relationship with the abuser?

Yes

Please provide information around the abusive behaviour, please try and include dates where possible

Has the abuser used weapons against you and/or others?

Yes

If yes, please provide details

Does the abuser have a criminal history/conviction(s) for violence?

Yes

If yes, please provide details

Has there been any threats or violence towards professionals by the abuser?

Yes

If yes, please provide details

Consent for storing and processing submitted data

Please read our privacy notice to find out how we process and use personal data.

I confirm that I give permission for my personal data to be stored and used for the purpose of completing my referral.