DASA Support Referral Form | MEWSo

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Section 1: About This Referral

Please confirm this person answered YES to meeting the criteria*

Yes

Has this person consented to being referred?*

Yes

No

What is your full name (the name of the person making the referral)*

Name of your organisation*

Address of your organisation*

What is your email? We may need to contact you for further information*

What is your contact telephone number?*

Section 2: Personal Details

If you are completing this form for yourself, please answer the questions below about yourself. If you are referring someone else, please answer the questions below about them.

What is your FIRST name? (your legal name as shown on your passport or birth certificate)*

What is your LAST name? (your legal name as shown on your passport or birth certificate)*

What is your date of birth?*

اليوم

الشهر

السنة

What is the name you prefer to be called?

What is your gender?*

What is your relationship status?*

Please list any physical, sensory, neuro-developmental or mental health needs that you have. Such as: anxiety, depression, trauma, bipolar disorder, ADHD, Autism, Chronic Fatigue Syndrome, Diabetes, Arthritis, Mobility Issues, Lupus, Deafness, Blindness, etc.

Long answer

Are you pregnant?

Yes

No

Have you experienced a pregnancy or infant loss?*

Yes

No

Have you ever experienced a traumatic birth?*

Yes

No

What is your nationality?*

What is your immigration status in the UK?

Select the option that best describes your current status. Your immigration status will not affect the support you can access and we will not share this information about you.*

What language do you prefer to communicate in?*

Do you speak any other languages?

Section 3: Address

What is the first line of your address*

Address Line 2

Address Line 3

Town or City*

Post Code*

Is your address safe to contact*

Yes

No

Are you currently, or have you recently been, living in a refuge or other domestic abuse safe accommodation?*

Yes

No

What is your current accommodation type?*

Section 4: Contact Details

If you are completing this form for yourself, please answer the questions below about yourself. If you are referring someone else, please answer the questions below about them.

Mobile Telephone Number

Mobile Safe To Contact?*

Yes

No

No mobile phone

Landline Telephone Number

Landline Safe To Contact?*

Yes

No

No Landline Number

Primary Email Address

Confirm email address

Email Safe To Contact?*

Yes

No

No Email Address

Please list any special instructions for making contact, including any times when contact should be avoided.

Section 5: GP Details

GP Surgery Name*

GP Surgery Address

GP Surgery Telephone Number*

Section 6: Referral Information

If you are completing this form for yourself, please answer the questions below about yourself. If you are referring someone else, please answer the questions below about them.

Please tell us about the situation and why support is being requested (include how the DASA Support referral criteria has been met)*

Please share any other information relevant to this referral, for example: any involvement of other agencies such as Social Services or Victim Support.

Section 7: Services Requested

Advocacy and Support (provided by Nafsiyat and MEWSo)*

Yes

No

Art Therapy Group (group sessions - provided by Mindworks UK)*

Yes

No

Counselling (in person - provided by Nafsiyat, Nour, Sister Circle and MEWSo)*

Yes

No

Counselling (online - provided by Nafsiyat, Nour, Sister Circle and MEWSo*

Yes

No

Group Therapy (provide by MEWSo in English, Arabic, Farsi and Kurdish)*

Yes

No

Healing Steps (wellbeing and support walks - provided by Nour)*

Yes

No

Healing Words (writing group - provided by Nour)*

Yes

No

Maternal Mental Health Peer Support (provided by Sister Circle)*

Yes

No

Theatre Therapy (group sessions - provided by Mindworks UK)*

Yes

No

Women's Health Conversation Caffe (provided by Sister Circle)*

Yes

No

Do you have a preferred DASA Support partner whose services you would like to access?*

Section 8: Equality and Diversity

If you are completing this form for yourself, please answer the questions below about yourself. If you are referring someone else, please answer the questions about them.

Do you consider yourself to have a disability under the Equality Act 2010?*

What is your sexual orientation*

What is your ethnicity?*

What is your faith or belief?*

Section 9: Dependant Children

If you have dependant children, please answer yes and provide their details in the boxes that appear, pressing the add child button to add more children as needed

Do you have any dependant children*

Yes

No

Please Note: This form only has room for up to 3 children. If you need to add more children, please include them and their details in an email, together with the mother's name and contact details, and send it to advice@mewso.org. Thank you.

مكاتبنا

St Mary's Neighbourhood Centre,

St Mary's Church,

Upper Street,

Islington, N1 2TX

Church Street Neighbourhood Centre,

Cherwell House,

Penfold Street,

Westminster, NW8 8PT

مؤسسة خيرية مسجلة: 1150129

منظمة المرأة والمجتمع الشرق الأوسطي (MEWSo)

إذا كنت بحاجة إلى المساعدة، أو كنت تعرف شخصًا يحتاج إلى مساعدتنا:

الإتصال:

07780 983 152

البريد الإلكتروني: office@mewso.org

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