Self referral form

Our service covers the Metropolitan district of Leeds only. All information given will be treated as strictly confidential.

This is a secure online form.

All information provided by you will be stored confidentially on our secure online case management system.

Section 1- About you

Your name(Required)

First Last

Date of Birth(Required)

Which gender do you identify as?(Required)

Your address(Required)

Postcode(Required)

Is it safe to post?(Required)

Do you live with the alleged person that caused harm ?(Required)

Your mobile Number(Required)

Is it safe for us to call you on this mobile number?(Required)

Do you give us permission to text you on this mobile number?(Required)

Is it safe to leave a message on this mobile number?(Required)

Do you answer calls from a withheld number?(Required)

Do you have a safe Email address?

Section 2- Children

Your children

First name

Surname

Date of birth 00/00/0000

Gender

Relationship to alleged person causing harm

Section 3 - Details of alleged person causing harm

What is your relationship to the alleged person that caused harm?(Required)

Details of alleged person that caused harm(Required)

First name

Surname

Date of birth

Gender

Address

Section 4- Reason for referral

Please give us as much detail as you can about your situation and why you are making this enquiry, this will help with our initial assessment, e.g. Types of abuse, relationship history, other agency involvement(Required)

Thank you for your enquiry. An initial assessment will take place to establish this is the right service for you. We will aim to contact you within 3 working days of receiving this enquiry to discuss the next steps.