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Self-referral

Please provide as much information as possible. If you have any questions, contact us on 01452 726570 or email support@gdass.org.uk.

Your details

Name *

Date of birth *

Date *

Address *

Telephone number *

Email address *

Ethnicity *

Gender *

First language *

Special needs *

None

Physical disability

Learning difficulty

Mental health condition

Complex needs

Are you open to social care? *

Yes

No

Not sure

Provide details of the circumstances that led to this referral (max 500 words) *

500 words left

Are you and the abuser in a relationship? *

Yes

No

Are you and the abuser separated but living in the same property? *

Yes

No

Abuser's details

Name *

Date of birth

Date

Address

Your children's details

Your children

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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.

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Gloucestershire Domestic Abuse Support Service (GDASS) is a county-wide service designed to reduce the level of domestic abuse and improve the safety of victims and their families.

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