Professional Advice and Advocacy Referral Form

This form is for professional use only. For self-referrals please call 0808 802 0300.

Please note, submission of a referral form does not grant access to advocacy services.

In sharing any personal details, you are confirming that you have the full, informed consent of the client to share their information with the National Stalking Helpline, and that they understand how we will store and process their data. Full details of how we handle personal data can be found at https://www.suzylamplugh.org/privacy-policy. Should you or the client require the privacy policy in a different format, please contact the Trust by phone on 0207 091 0014 or emailing [email protected]

Consent to refer?

YesNo

Referrer’s Details

Name (required)

Agency Type (required)

Organisation (required)

Job Title (required)

Phone (required)

Email address (required)

Details of case you are referring

Name (required)

Date of Birth (required)

Current Address (required)

Contact Telephone (required)

Area for Advocacy support (required)

NationalLondonCleveland

Is it safe to leave a voicemail? (required)

YesNo

Email Address (required)

Is it safe to email? (required)

YesNo

Primary Language (required)

Relationship to the stalker (required)

Current or previous police involvement (Crime Report Number if applicable) (required)

Criminal or Civil Order? (If yes, deadlines and restrictions) (required)

Known other Agency contact details (IDVA, Social Worker, etc) (required)

Details of children (if applicable) (required)

Immediate advocacy needs (police, courts, housing, etc) (required)

Gender Identity (required)

Sexual Orientation (required)

Religion (required)

Disability status (required)

Ethnicity (required)

What is the preferred language? (required)

Details of Stalker (if known)

Name

Date of Birth

Current Address

Known other agency contacts

Reason for referral

What is the purpose of the referral? This information is essential (Please give a concise account of the reasons for advocacy, any criminal proceedings and any deadlines. Advise or send any particularly relevant documents, specific risk concerns e.g. viol (required)

Send