DA Self Referral Form

Referrals Name*

First NameLast Name

Referrals Address*

Street Address

Street Address Line 2

TownCounty

Postcode

Your Contact number*

Your Email

Have you been affected by domestic abuse?

YesNoUnknown

Have you received support for domestic abuse by a professional?

YesNoUnknown

Name of your Domestic Abuse Support Professional

eg: Social Worker, IDVA, DA Support Worker, Police Officer, GP etc

Name of The Organisation of Your Domestic Abuse SupportProfessional

eg: Social Services, IDVA Services, Women's Refuge, Police, Doctors Surgery etc

Support Professionals Contact number

Support Professionals Email

Do you have children?

YesNo

Please provide full names and DOB's of referrers children:

Name, age, gender of each child and any special needs they may have

Name of your Housing Provider

eg: Places for People, Cross Key Homes etc

Please give a brief description of reason for referral, some background and any risk issues

What other sources of help/support/funding has been sought before applying to THE ANGELS FOUNDATION UK?*

Food bank, emergency grant, other charities?

Is the person referred aware of the referral to THE ANGELS FOUNDATION UK?*

YesNo

DISCLOSURE OF PERSONAL INFORMATION ABOUT SERVICE USERS TO THE ANGELS FOUNDATION UK AND THIRD PARTIES/OUTSIDE AGENCIES

1. In cases where staff members feel there is a need to disclose confidential information about a service user to a third party, they must inform the person concerned why there is a need to share information, with whom, and what the likely consequences of their agreeing or not agreeing to disclosures are.
2. Once consent has been obtained, it is the responsibility of the staff member passing on any information to ensure that disclosure only takes place on the terms agreed with the service user it concerns.
3. Information should only be given to other organisations with the service user’s permission, with the exception of the cases set out in the policy when disclosures may be made without consent.
4. Documentation in the form of photography and a written statement is necessary for evidencing our work and demonstrates the support of THE ANGELS FOUNDATION UK for fundraising and marketing purposes to the public. Any public disclosures are anonymised and protects the identity and location of our clients. By giving consent you are agreeing to the sharing of this documentation.
5. By referring this form to THE ANGELS FOUNDATION UK you are confirming you have obtained consent from your client to share their information with us in order to access our support services.
6. Beneficiaries are required to complete a feedback form/give a statement of feedback to THE ANGELS FOUNDATION UK once support has been given.

I/we understand the support given by the THE ANGELS FOUNDATION UK is not guaranteed and subject to available resources*

Yes

Date

Domestic Abuse Self Referral Form

Referral Details

Reason For Referral

Consent to Refer

The Angels Foundation UK is a Registered Charity: 1205725