Home > Contact > Make a Referral

Any organisation or individual can make a referral. If you refer yourself for support, we will direct your referral form to the appropriate service and someone will contact you within 72 working hours. All information is stored securely and we will treat your information as confidential and will not share it with any other agency unless we are required to do so by law, or unless any person will come to harm if we do not share it. If you are a professional referring a client, we may contact you for further information and to inform you of the referral outcome. All referrals are assessed and prioritised according to need and risk

    Service you are referring to

    Your Name (required)

    Your Email (required)

    Your Telephone number (required)

    Agency you represent

    Name of person you are referring

    Address of the person you are referring

    Date of birth for person you are referring

    Are there any dependent children? Please enter their names and ages in the box below.

    Safe contact details for person you are referring

    Is it safe to text?
    YesNo

    Is it safe to leave a voice mail on the house phone?
    YesNo

    Is it safe to leave a message on mobile?
    YesNo

    Does the person you are referring require an interpreter?
    YesNo

    If yes, which language is required?

    Reason for referral. (Please provide as much information as possible including the nature of abuse and the type of support required).

    Relationship status

    Name of alleged abuser

    Are the police involved?
    YesNoDon't know

    Police Incident Number

    Has a DASH assessment been completed?
    YesNoDon't know

    If a DASH assessment has taken place, what is the level of risk? (Please select an option)

    Does the person consent to IDAS support?
    YesNo

    Please type the letters and numbers below into the box.
    captcha

     

    You can also make a referral to us by ringing our helpline on: 03000 110 110

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