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 (WHM)
Art of Her (Leeds Beckett)
Bluebirds Online Group
Breathe Free
Family Canvas
Feel Good
Inside Out
Our Circle
Rainbow Hearts
Rosebuds
For LDVS referrals, visit https://ldvs.uk/ - For Pregnancy Choice Advocacy Service (PCAS) referrals, please complete our PCAS referral form on our website
Please note:
Feel Good is a health and wellbeing programme and does not provide domestic abuse support. If domestic abuse is the primary support need, please consider making a referral to Leeds Domestic Violence Service (LDVS) for appropriate specialist support. LDVS | Leeds Domestic Violence Services
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
2 digit day, 2 digit month, 4 digit year
Phone Number
*
Please enter a valid phone number.
Format: 00000 000 000.
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
Emergency Contact
Important information: The emergency contact must not be anyone whose involvement could put the woman or her children at risk. Please check it is safe and appropriate to include this person before providing their details. Please also include their relationship tot he woman.
Contact Number
Please provide their telephone number. We would only attempt to contact this person where absolutely necessary and appropriate.
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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
Please provide details of support currently being provided by Social Worker
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Reason for Referral
Please tell us why you are making this referral to Women's Health Matters.
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Please describe the current circumstances, the support she would benefit from, and what she hopes to achieve. If the referral relates to domestic abuse, please indicate whether the abuse is historical, ongoing, or both.
Are you aware of any risks relating to this person?
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Please include any relevant information about domestic abuse, contact with the alleged perpetrator, coercive controlling behaviours, stalking or harassment, mental health or substance use concerns, housing insecurities or MARAC involvement. Please include any known protective factors or safety measures in place.
Are you aware of any risks to WHM staff or volunteers when supporting this person?
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For example, threats or aggression towards professionals, concerning behaviour, or any other information that may affect staff safety. Please include any known precautions or safety arrangements. Please be aware that this will not impact on the level of support this person receives from WHM.
Will the woman require any additional support to participate in a group setting? If yes, please describe the support that may be helpful.
Would any adaptations or adjustments help the woman to participate fully in the group?
If yes, please describe any suggested adjustments, such as accessible information, communication support or changes to the group environment. WHM will endeavour to accommodate identified needs where possible, but we cannot guarantee that all requested adjustments can be provided.
Are there any known topics, situations, or discussions that may cause distress, or mean she needs additional support during a group session?
If yes, please provide relevant details and describe any support or approaches that may help her feels safe and supported.
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.
Check-In Calls
If the woman you are referring is placed on a waiting list, Women's Health Matters can offer a brief check-in call approximately once a month while she waits for support. These call provide an opportunity for her to discuss any changes in her circumstances or support needs.
Would the woman like to receive monthly check-in calls while waiting for support?
Yes
No
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Other Workers
Is the woman currently working with any other agencies?
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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.
Format: 00000 000 000.
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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