SELF-REFERRAL FORM
PLEASE COMPLETE AS FULLY AS POSSIBLE TO ENABLE US TO PROVIDE THE CORRECT SUPPORT - Thank you (please note ALL professionals MUST use the Professional Referral Form found on our website) Your privacy Matters: Compassion is committed to protecting your personal data in line with UK GDPR. To see how we look after your information, please read our full Privacy Policy at www.compass-ion.org
Your Details
Name
*
First Name
Last Name
Your Address
*
Street
Town/City
county
Post Code
Contact Details?
*
Rows
DETAILS?
SAFE TO CONTACT?
PHONE NUMBER
YES
NO
EMAIL ADDRESS
YES
NO
How do you describe your gender?
*
Is your current gender *DIFFERENT* from sex you were assigned at birth?
*
Please Select
Yes
No
Don't Know
What is your sexual orientation?
*
Straight / Heterosexual
Gay woman / Lesbian
Gay man
Bisexual
Pansexual
Something else
Don't know
*
Rows
Please complete
Date of Birth
Age
Does the perpetrator live at this address?
*
Yes
No
Don't know
What is your relationship status?
*
Civil partnership
Cohabiting/living together
Divorced
In a relationship (not living together)
Cohabiting but not married
Married
Separated
Single
Widowed
Other
Do you consider yourself to have any kind of disability? (please tick all that apply)
*
Physical
Learning
Mental Health
Deaf/hearing impaired
Blind/visually impaired
Don't Know
No
Other
If you stated "Other" Please state below
Accessibility requirements
*
Yes
No
Don't know
How would you describe your ethnicity?
*
Asian Bangladeshi
Asian British
Asian Indian
Asian Pakistani
Asian and White
Any other Asian background
Black African
Black British
Black Caribbean
Black African and White
Black British & White
Black Caribbean & White
Black Any other background
Chinese
White British
White Irish
White Gypsy or Irish traveller
Any other White background
Asian and White
Don't know
What is your nationality?
*
(If not a British National) What is your immigration status?
Do you have a faith / religion?
*
No religion
Bahai
Buddhist
Christian
Hindu
Jewish
Jain
Muslim
Shinto
Sikh
Zoroastrian
Other
Roman Catholic
Jehovah's witness
don't know
Employment status
*
Full time employment
Self-employed
Part time employment
Student
Unemployed
Other
Are you pregnant?
*
Yes
No
Don't know
Have you experienced any of the following?
Physical Abuse
Stalking/ Harassment
Financial Abuse
Honour Based Violence
Coercive Control
Sexual Abuse
Psychological Abuse
Forced Marriage
Child to parent violence/abuse
None of the above
CHILDREN (please enter any children you have)
Rows
Name/Initials
Date of birth
Age
Gender
Educational setting
Relationship to Perp
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6
Next of kin
*
Rows
Please complete
First name
Surname
Relationship to you
Contact number
In an emergency is it safe to contact your next of kin?
*
Yes
No
Reason for referral
About the abuse
Please provide a brief description about the abuse and support needed.
About the perpetrator?
Rows
Please enter below
First Name ( and any middle)
Surname
Perpetrator date of birth
Perpetrator age
Are you still in a relationship with the person named above?
Yes
No
Address/ last known address?
Street Address
Street Address Line 2
town
county
Post code
If you have you had a D.A.S.H risk assessment completed, please tell us the score.
If applicable; Risk - Outcome of score?
Low
Medium
High
Other Agencies involved with you/family
Rows
Name
Email
Phone number
Job role/title
Agency 1
Agency 2
Agency 3
Agency 4
Are/have the Police been involved?
*
Rows
Yes
No
Are the Police involved with you/& or your family?
Have the police previously been involved?
Services
Please select all services required
Tea and coffee morning (Sudbury
Befriending/check-in call
Escape the Trap programme (13-18 yrs)
Who's in charge programme (nationally - online
Who's in charge programme (Sudbury face-to-face)
Who's in charge programme (Haverhill face-to-face)
VOICE Programme (nationally - online)
VOICE Programme (Sudbury face-to-face)
VOICE Programme (Stowmarket face-to-face)
30 minute telephone free legal advice
Don't know
Please tell us how you heard about us
Leaflet/flyer
Word of mouth
Internet search
Social media
Friend/family
Professional
Other
Signature
*
Date
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
All our policies & procedures can be found on our website, including GDPR.
www.compass-ion.org
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