Service you are referring to*
LDAS SupportLDAS CounsellingLDAS Group ProgrammeBridgeNew Horizons

Your Name*

Your Email*

Your Telephone Number*

Agency you represent

Have you completed a Merit or DASH assessment?*
---YesNo

If a Merit / DASH assessment has taken place, what is the level of risk? (Please select an option)
HighMediumLow

Please provide a completed risk assessment if one has been completed.

Current worker support
e.g - Social Worker, IDVA, Complex worker
Please expand on why this level of support is necessary for this individual
i.e child protection level, high risk, higher support needs than high risk DA

What safeguarding measures have you completed?
e.g - Referred to MARAC, Contacted adult services (safeguarding), Contacted children’s services (safeguarding), Offered/ sought emergency accommodation

Name of person you are referring

Address of the person you are referring

Date of birth for person you are referring

Sexuality of the person you are referring
---HeterosexualHomosexualBisexualRather not say

Are there any dependent children? (please provide names/age/address if different from referral)

Safe contact details for person you are referring

Home Number

Mobile Number

Is it safe to text?
YesNo

Is it safe to leave a message on mobile?
YesNo

Does the person you are referring require an interpreter?
YesNo

If yes, which language is required?

Reason for referral
(Please provide as much information as possible including the nature of abuse and the type of support required).

Relationship status

Name of alleged abuser

Are the police involved?
YesNoDon't Know

Does the person consent to LDAS support? For LDAS to make contact the referrer must obtain consent.*
YesNo