Self Referral Form "*" indicates required fields Use this form is you would like to refer yourself to any of our services. If you are applying on behalf of a client, please complete our Agency Referral Form. If you have any questions about the application process please call us on 01273 612025 or email [email protected] Referral details:Type of service*Please pick at least one option. Domestic abuse victim/survivor over 16 Healthy relationship group for teenagers aged 13-16 Managing money safely group for women Parent experiencing abuse from child Trans and Non-Binary IDVA Service Other Type the "other" service here* Please let us know why you are making a referral. Include any safety concerns you have for yourself or your family.*Please contact CGL (East Sussex) 0300 323 9985 or Victim Support (Brighton & Hove) 08 08 16 89 111 if you are currently experiencing abuse from a partner or ex-partnerYour details:Fields not marked with an asterisk are optional. This data is collected for equalities monitoring purposes only.Name* First Last Date of Birth* Day Month Year AgeSex at birth* Male Female Preferred pronouns Identifies as transgender or non-binary? Yes No Gender if different from sex at birth: Address* Street Address City ZIP / Postal Code Safe contact number*Safe email* Ethnicity Religion How did you hear about us?Do you have any disabilities / literacy issues* Yes No You said 'Yes'. Please provide details*Sexuality Heterosexual Gay Lesbian Bisexual N/A (child) Other Do you have any children under 18?* Yes No You said 'Yes'. Number of children?*Please enter a number from 1 to 10.Subject to Child Protection Plan?* Yes No Currently pregnant?* Yes No Other support needs? Drugs Alcohol Mental Health Other Support in place from other services?* Yes No PhoneThis field is for validation purposes and should be left unchanged. Δ Getting HelpSelf Referral Form Agency Referral Form Referrals Donate
