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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)
DD slash MM slash YYYY

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

Details of alleged person that caused harm(Required)
First name
Surname
Date of birth
Gender
 

Section 4- Reason for referral

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.