Professional referral form

We kindly ask that all areas of the form are completed. This will allow us to quickly and effectively identify the client's risk and establish a timely and appropriate support plan.

If you require any support at the time of referral, please call our team on 0203 384 9412 or 0800 0124 924 out of hours.

Receipt of the referral will be within two hours.

The client will be contacted on the same day.

You will receive an update on how the case is progressing within five working days.

Email: referrals@aanchal.org.uk

Phone number: 0800 0124 924

Name of Referring Agency

Name of Professional Referring

Email

Phone

Date Referral Completed

Day

Month

Year

Victim Name

Victim Date of Birth (If Known)

Victim Gender Identity

Victim Address

Is is safe to contact the victim at this address?

Yes

No

Don't Know

Describe relationship and living arrangements.

Victim's Telephone Number

Is this number safe to call?

Yes

No

Unknown

Victim's email address

Is this address safe to email?

Yes

No

Unknown

BME?

Yes

No

Unknown

Disabled?

Yes

No

Unknown

Mental Health

Yes

No

Unknown

Substance Misuse?

Yes

No

Option Unknown

If the victim is disabled, please specify access / communication requirements (Under the Equality Act, 2010, a person is disabled if they have a physical or mental imparement that has a s'ubstantial ' and 'long term' negative on ability.

No recourse to public funds?

Yes

No

Unknown

Gang related issues?

Yes

No

Unknown

Housing provider & tenure (eg Housing association, private rent, home owner)

If known, please provide details of any children (names, DOB, ages, schools, who has parental responsibility (Does perpetrator?) and address where they live if different from above.

CYPS Involved?

Yes

No

Unknown

Perpetrator details if known (Name, age, DOB, gender identity, current address and relationship to victim)

Is the perpetrator currently in custody/ on remand/ on bail / subject to probation supervision? (please specify)

Long answer

Details of secondary perpetrator/s

Reasons for referral and level of risk (High, Medium, Low). Please also use check box below to indicate support required)

Domestic abuse recovery programmes - Jasmine or Standing Strong

FGM Casework / Advocacy

Civil Law Support (eg obtaining a non molestation order)

Support (including access to refuse)

Young persons independent domestic and sexual violence advocate

Independent domestic violence advocacy / casework

Independent sexual violence advocacy / casework

Criminal justice support (including support to report to police)

Immigration advice

LGBT specific support

Other (please specify below)

If 'Other' was ticked please provide details

Opening Hours

Mon - Fri

8:00 am – 8:00 pm

Saturday

9:00 am – 7:00 pm

Sunday

9:00 am – 9:00 pm

Professional referral form

​

Opening Hours