Women's Health Matters Referral Form
Please complete this referral form to the best of your knowledge. If you require any assistance or would like to discuss the referral before submitting please contact Referrals@womenshealthmatters.org.uk or contact the Women's Health Matters office on 0113 276 2851
Project being referred to:
*
Please Select
Art of Her
Bluebirds Online Group
Breathe Free
Digital Support
Family Canvas
Feel Good
Inside Out
Rainbow Hearts
Rosebuds
For Pregnancy Choice Advocacy Service (PCAS) referrals, please complete our PCAS referral form on our website
Details of the person being referred
Name
*
First Name
Last Name
Is this person known by any other name? Is so what do they prefer to be called?
Date Of Birth (DD/MM/YYYY)
*
/
Day
/
Month
Year
Phone Number
*
Please enter a valid phone number.
Can we text this number?
*
Yes
No
Can we leave a voicemail on this number?
*
Yes
No
Will they answer a withheld number?
*
Yes
No
Address
*
Street Address
Street Address Line 2
City
Post Code
Type of property:
*
Local Authority
Temporary Accommodation
Housing Association
Owner
Living with Friends/Family
Refuge/Hostel
Other
Does this person live alone? If not, please provide details of who they live with
Is it safe to send post out to this address?
*
Yes
No
Email
example@example.com
Is it safe to send emails?
Yes
No
Next of Kin Name and Relationship
*
Please gain specific consent to include this; if not given, write consent not given.
Next of Kin Contact Number
*
We may attempt to contact this person if we are unable to get through to the referee.
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Children
Does this person have any children under the age of 18? (either in their care or living elsewhere)
Please Select
Yes
No
Please provide name and DOB of all children. Please also indicate who the children live with.
*
Is the woman currently pregnant
*
Yes
No
If yes, please provide EDD.
Are Children's Social Work Services currently involved?
*
Yes
No
Please provide contact details for allocated social worker
If yes, please provide details of support currently being provided by Social Worker
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Reason for Referral
Please provide as much detail as possible as to why you are making this referral.
*
PLEASE CONSIDER WHAT SUPPORT WOULD BE BENEFICIAL AND THE OUTCOMES THE WOMAN WOULD LIKE TO SEE. If referring for support around DVA, please indicate whether this is historical/ongoing/both, whether the woman is still in the relationship etc.
Are there any risk factors you are aware of?
*
Please consider whether the woman is living with perpetrator, her MARAC status, mental health concerns, housing/social circumstances, or other risks within the home.
Are there any risks to workers?
*
If yes, please provide detail of the risk posed to workers. This will not affect the support offered to women.
Any access issues
*
Does the woman require an interpreter, have any physical accessibility needs, learning disabilities or need a creche in order to access support.
Any allergies?
*
Does the woman have any allergies that we need to be aware of? e.g. Nuts, wasps, medication, dairy, wheat, fruit etc.
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Other Workers
Is the woman currently working with any other agencies?
*
Yes
No
If yes, please provide their name, role, organisation and contact details
Referrer Details
Please provide your contact details
*
Name
Role/Organisation
Email Address
Telephone Number
Where did you hear about us?
Contact Email Address
*
example@example.com
Contact Phone Number
*
Please enter a valid phone number.
By submitting this form I confirm that the woman named has consented to a referral being made to Women's Health Matters. Without consent we will not be able to accept or process the referral.
*
Yes
No
I confirm that I have explained to the woman being referred that Women's Health Matters will be receiving, storing and using the information given on this form to process this referral and she has consented to this. Without consent we will not be able to accept or process the referral.
*
Yes
No
Submit
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