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Home > Contact > Make a Referral

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?

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

Is it safe to leave a message on mobile?

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?

Please type the letters and numbers below into the box.


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

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