Service you are referring to*
LDAS SupportLDAS CounsellingLDAS Group ProgrammeBridgeNew Horizons
Your Telephone Number*
Agency you represent
Have you completed a Merit or DASH assessment?*
If a Merit / DASH assessment has taken place, what is the level of risk? (Please select an option)
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)
Is it safe to text?
Is it safe to leave a message on mobile?
Does the person you are referring require an interpreter?
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).
Name of alleged abuser
Are the police involved?
Does the person consent to LDAS support? For LDAS to make contact the referrer must obtain consent.*