Type of Referral*

Has the person being referred consented to this referral?*

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

Name of your organisation*

Address of your organisation*

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?*

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.

Are you currently pregnant?

Have you experienced a pregnancy or infant loss?

Have you ever experienced a traumatic birth?

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.*

What language do you prefer to communicate in?*

Do you speak any other languages?

What is the first line of your address?*

Address line 2

Address line 3

Town or City*

Postcode*

Address - Safe to Contact?*

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

Current Accommodation Type*

Mobile Telephone No.

Mobile - Safe to Contact?*

Landline Telephone No.

Landline - Safe to Contact?*

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*

GP Surgery Address

GP Telephone Number*

Please tell us about the situation and why support is being requested (include how the SafeRoots referral criteria has been met)*

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

Advocacy & 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 (provided in Farsi and Arabic by MEWSO)*

Healing Steps (wellbeing & support walk - provided by Nour)*

Healing Words (writing group - provided by Nour)*

Maternal Mental Health Peer Support (provided by Sister Circle)*

Theatre Therapy (group session - provided by Mindworks UK)*

Women's Health Conversation Cafe (provided by Sister Circle)*

Do you have a preferred SafeRoots Partner whose services you would like to access?*

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*

Child's date of birth*

Child’s gender*

Who does the child currently live with?*

If Applicable, Please Explain Living Arrangements