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?
*
Please Select
I don't know
Art of Her
Bluebirds Online Group
Breathe Free
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
Your Details
Name
*
First Name
Last Name
Date Of Birth
*
/
Day
/
Month
Year
Mobile 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 you answer a withheld number?
*
Yes
No
Address
*
Street Address
Street Address Line 2
City
Post Code
Type of property
*
Local Authority
Temporary Accommodation
Owner
Private Rent
Living with Friends/Family
Refuge/Hostel
Other
Is it safe to send post out to this address?
*
Yes
No
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?
*
Yes
No
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 Select
Yes
No
Please provide name and DOB of all children. Please also indicate who the children live with.
*
Are you currently pregnant?
*
Please Select
Yes
No
If yes, please provide EDD
-
Day
-
Month
Year
Are you currently working with Children Social Work Services?
*
Yes
No
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 bit about what is going on for you at the moment, issues you may be struggling with or worries that you have. If you are experiencing, or have previously experienced Domestic Violence and Abuse please tell us a little about when this was and whether you still have contact with this person. You may also want to consider what you would find helpful and what outcomes you would like to see. This can help us in ensuring that you receive the best 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.)
*
Yes
No
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?
*
Yes
No
Submit
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