Name

Address

Date of birth

Is it safe to write to you at the above address? Is it safe to write to you at the above address? Yes No

Is there a safe way we can contact you? For example, a phone number or email account the person using abusive behaviours has no access to Is there a safe way we can contact you? For example, a phone number or email account the person using abusive behaviours has no access to Yes No

Is it safe to text you? Is it safe to text you? Yes No

Is it safe to leave you a voicemail? Is it safe to leave you a voicemail? Yes No

Is it safe to send you emails? Is it safe to send you emails? Yes No

Safe phone number

Safe email address

Safe days we can contact you Safe days we can contact you Monday Tuesday Wednesday Thursday Friday

Let us know safe times we can call you, for example, when you're able to talk when the person using abusive behavior is not around.

Communication needs - please specify any assistance you may need to communicate with our team, for example if you're hearing impaired.

Do you need an interpreter? Do you need an interpreter? Yes No

Which language?

Please tell us your current situation. What is happening to you and how this is affecting you and your main concerns. Common abusive behaviors include mocking, humiliation, insults, criticism, being checked up on, followed, or stalked, pressure, threats, intimidation, or violence, destruction of possessions, isolation from family and friends, being forced into sex, control over money, lying, blame and denial of the abuse.

Are there children in the household? Are there children in the household? Yes No

Are the police involved? Are the police involved? Currently Historically No

Are you referring someone else? Are you referring someone else? Yes No - I am referring myself

Your Name

Your email address

Your telephone number

If you are a professional, please tell us which organisation you work for

How did you hear about us? How did you hear about us?Our websiteOur social mediaGPKey workerPoster or information cardOther

Please State