Web Referral For Professionals

1. Name of referring agency *

2. Name of referrer *

3. Referrer Telephone *

4. Referrer Email *

5. Client Name *

If unknown, please enter a placeholder e.g. Sam Unknown

6. DOB *

If unknown, please enter a placeholder e.g. 01/01/1900

7. Client Telephone Number *

If unknown, please enter your own

8. Client Email *

If unknown, please enter your own

9. Is it safe to contact client via a phonecall *

No
Yes

10. Is it safe to contact client via a voicemail *

No
Yes

11. Is it safe to contact client via text *

No
Yes

12. Is it safe to contact client via email *

No
Yes

13. Any additional information, e.g. specific time or day that we can contact the client, etc.

Please note DAVSS helpline operating hours are 10am till 1pm and the office operates between 9am and 5pm. There is a manned voicemail service if you are not able to call during these hours and we can schedule a call back

14. Local Authority *

Sevenoaks
Tunbridge Wells
Tonbridge and Malling

15. Housing Address *

16. Is it safe to contact client via post *

No
Yes

17. Housing situation *

17a. If Housing Association Tenant, which Housing Association?

18. Gender *

19. Is this the assigned gender at birth? *

20. Pronouns *

21. Sexual orientation *

22. Ethnicity *

23. Religion *

24. Does the client have any disabilities? *

No
Yes

24a. If yes, please specify

24b. Any further disability details:

25. Are there any mental health issues? *

No
Yes
Unknown

25a. If YES please enter details here:

26. Have the mental health issues been diagnosed? *

27. Is there prescribed medication for the mental health issues? *

28. Number of children under 18 *

29. Reasons for referral. Please include description of recent incident(s), risk level if applicable, etc. Please be as detailed as possible (minimum 250 characters) *

30. Name of alleged perpetrator *

31. DOB of alleged perpetrator *

32. Gender of alleged perpetrator *

33. Are the client and alleged perpetrator living together? *

No
Yes
Unknown

GDPR Agreement *

I consent to having this website store my submitted information so they can respond to my inquiry.

DAVSS Consent *

The client has consented to be referred to DAVSS

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