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Details of Referral

Please enter details as required below. Note: this information will be collected and stored by Victim Support. Please refer to the VS privacy policy via www.new-era.uk for more details of how your data will protected.

Would you like the support for yourself or somebody else?(Required)

Specialist Service

I require Support service for a(Required)
Do you require dedicated service for:(Required)

Female

In case of an emergency, we encourage you to call 999 or contact the Police

Immediate Risk Assessment


Contact Details


Is it Safe to send post to this address?(Required)
Is it Safe to email?
Please select which number it is
Is it Safe to text on this number?(Required)
Is it Safe to leave message on this number?(Required)
Please select which number it is
Is it Safe to text on this number?
Is it Safe to leave message on this number?

Needs Assessment


Can you describe what you are requesting support for: Multiple choice – tick all that are applicable

Equality, Diversity & Inclusion


Translator required(Required)
Do you have any Disability?(Required)
Are you Pregnant?(Required)
Do you have Children?(Required)
Would you like to refer your children for support?(Required)

Details of Children


Please enter the details of your child or children.
Name DOB Relationship to child Do you have Parental Responsibility Any child contact arrangements/orders in place or pending through family court Are CAFCASS involved Action
indicates required field

On Behalf of - Person aged 16+

Please enter your details below

Does the person being referred know about this referral to New Era?(Required)

Contact Details for the Victim


Please enter the details of the person being referred

Is it Safe to send post to this address?(Required)
Is it Safe to email?
Is it Safe to text on this number?(Required)
Is it Safe to leave message on this number?(Required)
Translator required(Required)
Do they have any Disability?(Required)
Are they Pregnant?(Required)
Do they have Children?(Required)
Would you like to refer their children for support?(Required)

Details of Children


Please enter the details of their child or children.
Name DOB Relationship to child Do you have Parental Responsibility Any child contact arrangements/orders in place or pending through family court Are CAFCASS involved Action
indicates required field

AGENCY Referral - Person aged 16+ Referral form (Police)

In case of an emergency, we encourage you to call 999 or contact the Police

Enter your details


Contact Details for the Victim


Please enter the details of the person being referred

Is it Safe to send post to this address?(Required)
Is it Safe to text on this number?(Required)
Is it Safe to leave voice message on this number?(Required)
Translator required(Required)
Do they have any Disability?(Required)
Are they Pregnant?(Required)
Do they have Children?(Required)
Would you like to refer their children for support?(Required)

Details of Children


Please enter the details of their child or children.
Name DOB Relationship to child Do you have Parental Responsibility Any child contact arrangements/orders in place or pending through family court Are CAFCASS involved Action
indicates required field

AGENCY Referral - Person aged 16+ Referral form

In case of an emergency, we encourage you to call 999 or contact the Police

Enter your details


Contact Details for the Victim


Please enter the details of the person being referred

Is it Safe to send post to this address?(Required)
Is it Safe to email?
Is it Safe to text on this number?(Required)
Is it Safe to leave voice message on this number?(Required)
Can you describe what you are requesting support for: Multiple choice – tick all that are applicable
Translator required(Required)
Do they have any Disability?(Required)
Are they Pregnant?(Required)
Do they have Children?(Required)
Would you like to refer their children for support?(Required)

Details of Children


Please enter the details of their child or children.
Name DOB Relationship to child Do you have Parental Responsibility Any child contact arrangements/orders in place or pending through family court Are CAFCASS involved Action
indicates required field

Are you aware of any of the following in place:


Person under age 15

In case of an emergency, we encourage you to call 999 or contact the Police

Safe Contact details


Do you give us consent to contact this person

Contact Details


Is it Safe to send post to this address?(Required)
Is it Safe to email?
Please select which number it is
Is it Safe to text on this number?(Required)
Is it Safe to leave message on this number?(Required)
Please select which number it is
Is it Safe to text on this number?
Is it Safe to leave message on this number?

Needs Assessment


Can you describe what you are requesting support for: Multiple choice – tick all that are applicable

Equality, Diversity & Inclusion


Translator required(Required)
Do you have any Disability?(Required)

On Behalf of - Person under age 15

In case of an emergency, we encourage you to call 999 or contact the Police

Enter your details


Note: We cannot contact young people directly and need to arrange our service via a safe contact in the first instance, this is usually someone with Parental Responsibility. Please provide a named safe contact to call on your behalf to arrange support

Safe Contact details


Consent for us to contact your safe contact

Contact Details of the Young person


Please enter the details of the young person being referred

Is it Safe to send post to this address?(Required)
Translator required(Required)
Do they have any Disability?(Required)
Have you reported your concerns to the police?(Required)

Agency Referral - Person under age 15

In case of an emergency, we encourage you to call 999 or contact the Police

Note: We cannot contact young people directly and need to arrange our service via a safe contact in the first instance, this is usually someone with Parental Responsibility. Please provide a named safe contact to call on your behalf to arrange support

Safe Contact details


Have you obtained parental consent to refer the young person to New Era

Referring Agency


Please enter the agency you represent(Required)

AGENCY Referral - Person under 15 Referral form (Police)

In case of an emergency, we encourage you to call 999 or contact the Police

Enter your details


Note: We cannot contact young people directly and need to arrange our service via a safe contact in the first instance, this is usually someone with Parental Responsibility. Please provide a named safe contact to call on your behalf to arrange support

Contact Details for the Victim


Please enter the details of the person being referred

Is it Safe to send post to this address?(Required)

Agency Referral - Person under age 15 (Other agencies)

Contact Details for the Victim


Please enter the details of the person being referred

Is it Safe to send post to this address?(Required)
Is it Safe to email?
Is it Safe to text on this number?(Required)
Is it Safe to leave voice message on this number?(Required)
Can you describe what you are requesting support for: Multiple choice – tick all that are applicable

Equality, Diversity & Inclusion


Translator required(Required)
Do they have any Disability?(Required)

Alleged Perpetrator Details

Immediate Safety Needs

If Yes, please call us on 0300 303 3778

Data use/collection

(Tick all that apply):
Please tick here to confirm you are happy with our privacy notice
Thank you for referral
We aim to respond within 2 working days

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