Who is making this referral?*

Has the person being referred consented to this referral?*

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

Name of your organisation*

Address of your organisation*

Your address (address of person making referral)*

What is your email address? (we may need to contact you for further information)*

What is your contact telephone number?*

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

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

What is your date of birth?*

What is your preferred name?

What is your gender?*

What is your relationship status?*

Please list any physical, sensory, neurodevelopmental or mental health needs you have. 
E.g. Anxiety, Depression, Trauma, Bipolar Disorder, ADHD, Autism, Chronic Fatigue Syndrome, Diabetes, Arthritis, Mobility Issues, Lupus, Deafness, Blindness, etc.

Has a crime been committed against you? (if you don’t wish to disclose this you can choose the ‘Prefer Not To Say’ option in list)*

What language do you prefer to communicate in?*

Please list any other languages you speak.

What is your nationality?*

Immigration Status in the UK

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

Are you currently living with ongoing abuse?*

Is there anything else in your life that you feel is harmful or potentially harmful to you, that you would like to share?*

Please briefly share any details you feel will be helpful for us to understand your situation.

What is the first line of your address?*

Address line 2

Address line 3

Town or City*

Postcode*

Is it safe to use this address for written contact?*

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

List the people you live with e.g. partner/spouse, my own children, my parents, siblings, in-laws, step-children, friends, flat mates, foster children, etc.*

Which best describes your current accommodation type?*

Mobile Number

Is it safe to make contact by mobile?*

Landline Number

Is it safe to make contact by landline?*

Primary Email Address

Email - Safe to Contact?*

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

GP Surgery Name (for Emergency Use Only — referral cannot be accepted without these details)*

GP Surgery Address

GP Telephone Number

Please tell us about the situation and why support is being requested (include how Nour’s referral criteria have been met)*

Please share any other information relevant to this referral, e.g. involvement of other agencies such as social services or victim support.

Free Counselling – Online (UK Wide)*

Free Counselling - In Person (London only)*

Pathways To Healing (Not free, paid counselling service)*

Advocacy & Support*

Legal Advice*

Financial Support*

Healing Steps Walking Group (Women only - London Only)*

Healing Through Words (Writing Group)*

Spiritual Advocacy*

If financial support has been requested, please describe the current financial situation and what support is being sought.*

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?*

Do you have any dependant children?*

Child’s first name*

Child’s surname*

Date of Birth*

Child’s gender*

Who does the child currently live with?*

If Applicable, Please Explain Living Arrangements