Referral Forms

NOTTINGHAMSHIRE WOMEN’S AID REFERRAL FORMS

DOMESTIC ABUSE SUPPORT SERVICES (DASW)

Nottinghamshire Women’s Aid DASW service offers support and advice for all women are or have experienced domestic abuse or are wanting to escape from domestic abuse. 

The aims of the service:

• To listen and respond appropriately to survivor’s experiences of domestic abuse
• To give time and space for survivors to explore their experiences and make choices that are right for them and at the right time
• To ensure survivors are aware of their rights in relation to domestic abuse
• To provide group programmes for women to learn about perpetrator behaviour and the impact of domestic abuse in order to build strength and resilience
• To provide a 1:1 support service 
• To assess, support and manage risk in relation to domestic abuse and safeguarding
• To provide accessible support for all female survivors of domestic abuse

The DASW service includes:

The Freedom Programme:

• The Freedom Programme looks at the behaviours and tactics used to ensure power and control can be gained over another human being. It covers all aspects of domestic abuse through 10 topics
• It is a small group programme that is run either face to face or through Teams 

The DASW service:

• Provides 1:1 support for survivors, including having a named key worker who will work with you around to empower choices that are right for you

Eligibility criteria for the DASW Service:

• Self and professional referrals are accepted with consent
• Female survivors are over the age of 16 years
• Survivors live in the North Nottinghamshire area; Bassetlaw, Mansfield, Newark and Sherwood

FOR PROFESSIONAL REFERRALS A CURRENT DASH RISK ASSESSMENT IS REQUIRED TO BE ATTACHED

DASW Referral Form – inc. Freedom Programme

Name *

Organisation *

Phone Number *

Email *

Please indicate your agency type *

• Another DV service (generic)
• Another DV service (specialist
• Adult social services
• Children’s services
• Drugs/ alcohol
• Education
• Health
• Helpline
• Probation
• Police
• Voluntary/ community group
• Other
• Professional Referral

How did you find out about our service? *

• Flyer/ poster
• TV/ Radio
• Online
• Word of mouth
• Made a referral before
• Used the service before
• NDVH
• Another service

Did you find out about our services in another way?

Please enter the name and DOB of the person you’re referring: *

First

Last

Other/Previous Names

First

Last

Date of Birth *

Reason for Referral *

What would the survivor like from this referral to the DASW service? *

Client referred for support around (tick all that apply) *

• Coercive control
• Physical abuse
• Sexual abuse
• Emotional/psychological abuse
• Financial abuse
• Harassment/ stalking
• Sexual exploitation
• Trafficking
• FGM
• HBV
• Forced Marriage
• Other

How many children does the client have?

Selected Value: 0

Please consider if children require support from NWAL ChDASW team and as for further information

Please provide children’s names and DOB if known:

Are social services involved? Please give details

Name of social worker (if relevant)

First

Last

Freedom Programme only: If a crèche is available how many spaces would be required

Contact information about the person being referred: *

• Telephone
• Email
• Address

Tick all acceptable contact methods

Telephone number/s

Safe to contact by telephone? *

• Yes
• No

Safe contact notes for telephone: *

Email address

Safe to contact by email: *

• Yes
• No

Safe contact notes for email: *

Address

Safe to contact at address: *

• Yes
• No

Safe contact notes for address: *

Borough where currently resident: *

Is the client living with the perpetrator/s?

Is the client currently in refuge accommodation?

If the client is under 18, has parent/carer consent been sought for the referral?

• Yes
• No, not sought
• No, not safe to seek

Has the client used our service before?

• Yes
• No
• Not sure

Is the client currently pregnant?

• Yes
• No
• Not sure

If yes, due date:

Primary Language:

Other languages spoken:

How would they describe their gender?

Female, male or add preferred gender description.

Is the client's gender different to the gender they were assigned at birth? (are they transgender):

• Yes
• No
• Don’t know

Client's Ethnicity: *

• White British
• White Irish
• White Gypsy or Irish Traveller
• Any other White background
• Asian British
• Asian Indian
• Alan Pakistani
• Asian Bangladeshi
• Any other Asian background
• White and Black Caribbean
• White and Black African
• White and Asian
• Any other mixed/multiple background
• Black British
• Black African
• Black Caribbean
• Any other Black background
• Chinese
• Arab
• Any other ethnic group
• Don’t know
• Prefer not to say

Does the client have a faith/religion?

• No religion
• Bahai
• Buddhist
• Christian
• Hindu
• Jewish
• Jain
• Muslim
• Shinto
• Sikh
• Zoroastrian
• Any other religion
• Don’t know

What is their nationality?

Add nationality, ‘Prefer not to say’ or ‘Don’t know’

What is their relationship status?

• Civil partnership
• Married
• Divorced
• Separated
• Cohabiting but not married
• In a relationship (not cohabiting)
• Widowed
• Single
• Prefer not to say
• Don’t know

How would they describe their sexual orientation?

• Heterosexual/straight
• Gay woman/Lesbian
• Gay man
• Bisexual
• Don’t know
• Prefer not to say

Sexual orientation (if not covered by multiple choice)

Disability?

• Physical
• Learning
• Deaf/hard of hearing
• Blind/visually impaired
• Prefer not to say
• Other

Check all that apply.

Please tell us more about any support needs the client may have:

Does the client have recourse to public funds?

• Yes
• No
• Not sure

Support needs around alcohol?

• Yes
• No
• Not sure

Support needs around drugs?

• Yes
• No
• Not sure

Support needs around mental health?

• Yes
• No
• Not sure

BSL/interpreter required?

• All of the time
• Some of the time
• No
• Not sure

Does the client have any accessibility requirements?

• Yes
• No
• Not sure

Does the client have any previous convictions?

• Yes
• No
• Not sure

Addition support information:

If you have any other important/useful information about this person’s support needs, e.g. cultural needs, please provide additional details.

Are there any known risks to working with this client?

Information about the perpetrator, if known:

Client's Next of Kin

Please provide information for client’s next of kin/someone we can contact in an emergency

Submit

Thank you for completing the referral.  

Please inform the survivor of the following: 

• Her information will be kept on a secure electronic case management system 
• We will contact the survivor using the contact details provided. This will be from a withheld number. If there are any changes in circumstances or contact details, please let us know 

• If there are any further questions from both survivor or professional please e mail: enquiries@nottswa.org