Working Together to End Domestic Abuse in Devon

08082 816161

EXIT WEBSITE

Home
What is Domestic Abuse?
Who Do We Support?
Alliance Partners
Referral
Contact

Request for Support

Please complete this form with as much detail as possible. This form is treated as highly confidential and will only been seen by relevant staff members within the Devon Domestic Abuse Alliance .

Please read our privacy notice for information on how we use, store and manage the information you provide here

Request for Support

Part 1 – Please can you tell us a bit about yourself:

First Name

Last Name

Any previous names if know

Date of Birth

Address

Address Line 1

Address Line 2

City/Town

Postcode

Telephone

Is it safe to call you?

Yes

Is it safe to Text you?

Yes

Is it safe to Email you?

Yes

Do you have a time or day in the week that is safest to contact you?

Do you have time and days in the week that we should avoid calling you on?

What is your relationship to the person causing harm?

Partner

Spouse

Ex-Partner

Ex-Spouce

Family Member

Child

Other

If Ex-Partner/Ex-Spouse, how long has it been since separation:?

What is your living Situation

Are there any children in the Household?

Yes

Please add names and dates of birth of children

Are there any other family members affected and/or at risk from this situation, (including pets and animals):

Your GP Surgery (if known):

Are you or could you be pregnant:

Yes

Due Date

Do you have any communication needs such as needing an interpreter?

Yes

What do you need?

Do you have any other needs that may be important for us to know, such as disability needs, mental health concerns and so on:

Part 2 - Summary of what's happening

Please give us a description of what you are seeking support for:

Has this situation recently escalated?

Yes

If yes can you say how this has changed and what concerns do you have for your safety:

Do you know if the person causing you harm has any police orders in place such as police bail or family court arrangements:

Yes

Please can you give details if known

What would you like to happen and how best can we help you to feel safe?, don’t worry if you don’t know the answer to this at this time

Please can you give us some information on the person causing you harm. You do not need to complete this section if you don’t want to.

First Name

Last Name

Date or Birth

Do you know their address:

Yes

Address:

Is the person causing you harm threatening or at risk of suicide:

Yes

Please explain:

Please give any further details or information that you think may be relevant:

By completing this self-referral form you are consenting to us storing and processing your data in accordance with our records policy and for us to contact you to respond to your request for support.