Section 1: About This Referral Please confirm this person answered YES to meeting the criteria*
Has this person consented to being referred?*
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?*
What is the name you prefer to be called?
What is your relationship status?*
Please selction an option
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.
Have you experienced a pregnancy or infant loss?*
Have you ever experienced a traumatic birth?*
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.*
Please selection an option
What language do you prefer to communicate in?*
Do you speak any other languages?
What is the first line of your address*
Is your address safe to contact*
Are you currently, or have you recently been, living in a refuge or other domestic abuse safe accommodation?*
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.
Landline Telephone Number
Landline Safe To Contact?*
Please list any special instructions for making contact, including any times when contact should be avoided.
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)*
Art Therapy Group (group sessions - provided by Mindworks UK)*
Counselling (in person - provided by Nafsiyat, Nour, Sister Circle and MEWSo)*
Counselling (online - provided by Nafsiyat, Nour, Sister Circle and MEWSo*
Group Therapy (provide by MEWSo in English, Arabic, Farsi and Kurdish)*
Healing Steps (wellbeing and support walks - provided by Nour)*
Healing Words (writing group - provided by Nour)*
Maternal Mental Health Peer Support (provided by Sister Circle)*
Theatre Therapy (group sessions - provided by Mindworks UK)*
Women's Health Conversation Caffe (provided by Sister Circle)*
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?*
Please selction an option
What is your sexual orientation*
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*
