Adult victim / survivor community referral

This form is for professionals who are referring someone they are working with for support. Please provide as much relevant information as possible to help us assess risk and respond appropriately.

We may contact you for additional details and to confirm the outcome of the referral.

Referrer details
Victim / survivor details
Victim / survivor needs
Perpetrator details

Referrer details

Victim / survivor details

Current accommodation

Domestic Abuse/Stalking Experience

Name of Social Worker (if allocated)

Details of Members of the household

Victim / survivor needs

Cultural / religious needs

Perpetrator details

Example: access to fire arms, substance use

Privacy Notice

This referral form once completed will be sent to Southern Domestic Abuse Service trading as Stop Domestic Abuse of PO Box 53 Havant, PO9 1JW, who is the Data Controller in charge of processing personal data provided. Stop Domestic Abuse will process your personal information in order to assess, manage, deliver and develop any services we provide for you and provide anonymous statistical reports to the organisations that fund our work.  We will process your data on the basis of our legitimate interests to report to organisations that fund the work we do and to provide the best service to our clients.  We will process your ethnic origin, sexual orientation, health and religious information for the purpose of reviewing equality of opportunity within our service, you can choose not to give this information to us and withdraw your consent to us processing this information by emailing DPO@stopdomesticabuse.uk. If you are offered safe accommodation we will pass your information to the relevant landlord, they will treat your information as confidential in line with Management Agreements in place. Stop Domestic Abuse have sub-contractual arrangements in place for elements of the service offer, if this best meets your needs, your information will be passed to our partners. With your consent we will pass on information about you, including your contact details, to other organisations who provide services to meet your needs.  We will only pass your information on without your consent if we have concerns for a child or vulnerable adult or we are compelled by law. As data controller, we will not keep your information longer 10 years following you finishing receiving support from the organisation and will strive to keep it up to date.  You have the right, under the Data Protection Act 1998 and the General Data Protection Regulations 2018, to see and if necessary, correct personal data we hold about you.  Please contact us if you would like to see the information held on you, or if you do not wish to be contacted by us in the future. If you have any questions about how we will use your information please talk to one of our staff.