Self Referral Form - Domestic Abuse Recovery Programmes

Full Name*

Date of Birth*

Date

Address*

Contact Number*

Email*

example@example.com

Preferred Contact Method (e.g., phone, email)*

Safe Times to Contact*

Which best describes you?*

In an abusive relationshipRecently left an abusive relationshipIn need of advocacyI need help navigating post relationship abuseMy whole family needs domestic abuse recoveryI'm ready to move forward

Our programmes are designed to support individuals who are ready to take steps towards moving forward from experiences of abuse, including offering guidance and support for their children.

For specialist support tailored to your current needs, Gloucestershire Domestic Abuse Support Services (GDASS) may also be able to assist. More information can be found here:

GDASS Domestic Abuse Support

We understand that seeking support is an important step, and we encourage you to explore the best options available. If you need further guidance, we are happy to assist where possible.

Are you working with another professional or social worker regarding your situation?*

YesNo

To ensure a smooth process for you, we kindly ask that the professional you are working with completes our referral form for professionals or children services.

This will allow us to clarify important details before proceeding with your referral for recovery support.

Referrals can be submitted directly via our website at:
HTWG Referrals

If you require specialist support tailored to your current needs, Gloucestershire Domestic Abuse Support Services (GDASS) may also be able to assist. You can find more information here:GDASS - Domestic Abuse Support

We understand that reaching out for support is a significant step, and we encourage you to explore the options that best suit your circumstances. If you need any further guidance, we’re more than happy to assist wherever possible.

Child's Name

First & surname

Date of Birth

Date

Name of School

School Address

Contact Person at School if applicable

Contact Number for School

Are There Any Concerns Regarding the Child's Behaviour or Academic?

YesNo

Are school staff aware of the domestic abuse situation?

2nd Child's Name

Date of Birth

Date

Name of School

School Address

Contact Person at School if applicable

Contact Number for School

Are There Any Concerns Regarding the Child's Behaviour or Academic?

YesNo

Are school staff aware of the domestic abuse situation?

3rd Child's Name

Date of Birth

Date

Name of School

School Address

Contact Person at School if applicable

Contact Number for School

Are There Any Concerns Regarding the Child's Behaviour or Academic?

YesNo

Are school staff aware of the domestic abuse situation?

Have Any Other Agencies Been Involved Previously?*

YesNo

If yes, Organisation(s)?

Nature of Support Provided:

Are Any Other Organisations or Services Currently Supporting the Family?*

YesNo

If yes, please specify: Name of Organisation(s): Name of Contact Person(s): Type of Support Provided (e.g., legal aid, housing assistance, therapeutic services):

Please Briefly Describe Why You Are Seeking Support: For example, challenges with emotional wellbeing, parenting difficulties, or safety concerns.*

What Are Your Main Concerns at This Time? For example, feeling unsafe, needing help with recovery, or support for your children.*

Do You Feel Safe in Your Current Environment?*

YesNo

Are You Currently Receiving Support from Any Other Organisations or Services?*

YesNo

If yes, please specify who is helping you and the type of support they are providing.*

What Areas of Support Would Be Most Helpful to You? Examples could include counselling, parenting support, housing advice, or emotional recovery.*

Would You Like Support for Your Children’s Recovery?*

YesNo

If yes, please specify any concerns or needs your children may have.

Are There Any Special Requirements We Should Be Aware of? For example, cultural, religious, or language needs, or any disabilities.

Any Additional Notes or Information You Would Like to Share:

Declaration of Consent
By completing this form, I confirm that I am requesting support and give consent for the Domestic Abuse Recovery Programme team to contact me regarding my referral.

Referring Agency Declaration / confirm that / have explained the purpose of this referral to the client, and they have given their consent to participate in our Domestic Abuse Recovery Programmes.

Referring Person's Signature*

Date*

Date