Groupwork referral - Stop Domestic Abuse

Our services are available to those living in Hampshire, including Portsmouth and Southampton.*

I confirm that the individual being referred is based in Hampshire (including Portsmouth or Southampton)

To find out about support in other areas of the country please visit womensaid.org.uk/information-support/womens-aid-directory

Select the group you wish to make a referral to

Client's Details

Name*

First

Last

Date of birth*

Ethnicity of the client*

Please provide details of other ethnicity

Is the client registered disabled?*

Yes

Phone*

Please enter a phone number that it is safe for us to call

When is it safe to call this phone?*

Please enter a phone number that it is safe for us to call

Can a message be left on this phone?*

Yes, voicemails can be left on this number

No, please don't leave a voicemail on this number

Email address*

Address. Please include the postcode.*

Is your client living with an abusive partner or family member?*

Yes

Details of family members in the household.*

Please provide their full name, relationship to client, date of birth and gender.

Would the client prefer a face to face or a virtual group?*

Face to face

Virtual

Referrer's Details

Referrer's name*

First

Last

Referring agency*

Referrer's email address*

Perpetrator's Details

Name of the alleged perpetrator (if you know it)

First

Last

Date of birth of the alleged perpetrator

Relationship of the alleged perpetrator to client*

Has the client consented to this referral?*

Yes - full consent provided

No consent given

Information about Challenging Child

Name of child

First

Last

Child's date of birth

Please tell us a little summary of what has been happening