+Choices Referral

Consent

In order to submit a referral you must confirm your consent if it is for yourself, or that consent has been given by the individual if it is for someone else.

1. Emergency Accommodation

Referrals for emergency accommodation are only accepted where certain eligibility criteria are met, and the individual does not have access to their own funds or alternative accommodation.

All referrals, including for Emergency Accommodation, must:

Be made aware of the +Choices programme by the referrer
Have recognised and accepted that their behaviour is abusive
Be willing to engage in a programme designed to change their behaviour.

2. Perpetrator Details

Phone Number*

Email Address

Accommodation status*

Preferred language (if not English)

Any other agencies involved*

3. Victim Details

Phone Number*

Email Address

Preferred language (if not English)

Any other agencies involved*

4. Details of any Children

Children

Please add the details of any children involved below:

Name of Child	Actions

There are no Children.

5. Referrer Details

Referrer Contact number(s)*

Referrer Email Address*

6. Reasons for Referral

Please provide as much detail as possible about the individual/your situation and why this referral is being made.

Reasons for Referral*

7. Additional Police Referral Details

Incident number

Court date: (if applicable)

Offence: (if applicable)

Any warning markers/concerns?

Referral Submission

If you are sure all of the details provided are correct where known, please click the button below to submit this referral.