Self-Referral Form

Self-Referral Form
Please have a look on our website to find out about each project we offer. You can find this on the 'Our Services' page. https://www.womenshealthmatters.org.uk/services
Which project would you like to be referred to?
For LDVS referrals, visit https://ldvs.uk/ - For Pregnancy Choice Advocacy Service (PCAS) referrals, please complete our PCAS referral form on our website
Your Details
Name

First NameLast Name
Date Of Birth

DayMonthYear
Mobile Number
Please enter a valid phone number.Format: 00000 000 000.
Can we text this number?
Can we leave a voicemail on this number?
Will you answer a withheld number?
Address

Street Address

Street Address Line 2

City

Post Code
Type of property
Is it safe to send post out to this address?
Email
We will use your email address to send you confirmation that we have received and processed your referral. Please enter N/A if you do not have an email address.
Is it safe to send you emails?
Next of Kin Name and Relationship to you
Next of Kin Phone Number
We may contact this person if we cannot get hold of you
Children
Do you have any children? (either living with you, or living elsewhere)
Please provide name and DOB of all children. Please also indicate who the children live with.
Are you currently pregnant?
If yes, please provide EDD

DayMonthYear
Are you currently working with Children Social Work Services?
If yes please provide the contact details for your allocated social worker.
Reason for Referral
Please tell us how we can help you. Please provide as much detail as you can.
Please tell us a little about what is currently happening for you, including any difficulties, challenges, or worries you may be experiencing. If you are experiencing, or have previously experienced, domestic abuse, please share as much as you feel comfortable about when this occurred and whether you still have contact with the person involved.You may also wish to tell us what kind of support you feel would be helpful and what outcomes you would like to achieve. This information helps us understand your situation better and ensures we can provide the most appropriate support for you.
Are there any risks to you or our workers?
For example, please let us know if you have recently been referred to MARAC, if you are currently living with an abusive partner, if there are any dogs at the property or any other risks within the home. Please know that any risk will not affect the support you receive.
Do you require any support to access our groups?
Do you require an interpreter, have a physical accessibility need, learning disability or need a creche in order to access support.
Please tell us about any allergies you have
Examples nuts, wasps, medication, dairy, wheat, fruit etc.
Other Professionals
Are you working with any other professionals? If yes, please tell us their name, the organisation they work with and what they have been supporting you with.
Please enter N/A if not working with other professionals
Do you have a personal connection with anyone who works at WHM? (e.g. as a friend, relative, neighbour etc.)
If yes, who?
Data Protection
By giving us this information you are consenting for WHM to store your information on our systems and to use it in order to contact you. Do you consent to this?
Should be Empty:

Self-Referral Form

Your Details

Children

Reason for Referral

Other Professionals

Data Protection