Ashfield domestic abuse self-referral form

Preferred method of communication: *

Telephone call

Text

Email

Is it safe to make contact? *

Yes

No

Is it safe to phone? *

Yes

No

Is it safe to leave a message on this phone? *

Yes

No

Is it safe to text? *

Yes

No

Is it safe to send a letter? *

Yes

No

Is it safe to email? *

Yes

No

Are reasonable adjustments needed? *

For example: Ground floor access, a hearing loop, etc.

Yes

No

Do you speak English? *

Yes

No

Can you read English? *

Yes

No

Do you require an interpreter? *

Yes

No

Are you getting any support from other agencies for your situation?

For example: Nottinghamshire Police, Juno Women's Aid, Equation, etc. This will not prevent the domestic abuse team working with you but will help to prevent duplication and that you have the right services to support you.

Yes

No

Do you agree to your details being shared with Juno Women's Aid / Equation?

Yes

No