WORTH services self-referral form - 7994 This form will take approximately 15 minutes to complete.Please allow yourself enough time to complete this form in one session as there is not an option to save and come back to it later. The questions marked with an asterisk (*) are mandatory and require an answer. The more information you can provide, the better we are able to help you. Your data privacyBefore completing this form please read our general Privacy Policy (opens in a new window).This explains why we ask for your data, what we do with it and how long we will keep it. It also explains how you can find out what data we hold about you and how you can ask us to delete it. ConfidentialityPlease read our confidentiality policy (opens in a new window)before completing this form. This explains what may happen to the information that you share with us and when we may need to safeguard you or others. Your details Title Select your title. Select an option Mr Mrs Miss Ms Mx Dr Other Other Enter your title if it is not listed above. First name * Enter your first name. Last name * Enter your last name. What is your date of birth? * Enter your date of birth in the format DD/MM/YYYY, for example 01/01/1901. If you are under 18, we may need to speak to other people about your situation. This is to make sure that you are safe. We will always try to get your consent first and will tell you that we are sharing information. House name or number * Enter your address name or number. This could be the flat, house or building name or number. Address line 1 * Enter the first line of your address. This could be the street name. Address line 2 Enter the second line of your address if you need to. This could be the village name. Town or city * Enter the town or city of your address. Postcode * Enter your postcode, with or without spaces. Phone number * Enter a daytime phone number that we can ring you on. This can be a mobile or land line number. Is it safe to call, text or leave a voicemail on this number? * Select yes, anytime if it is safe, yes but only at certain times if it is only safe some of the time or no if it is not safe to call you. Yes, anytime Yes, but only at certain times No When is it safe to contact you on this number? Let us know when it is safe for us to contact you. Email address * Enter an email address where we can write to you. What is your preferred contact method? * Choose how you would like us to contact you. Phone Email Do you have any children under the age of 18? * Answer 'yes' if you have children who are under 18 years of age. Answer 'no' if you do not have children, or if your children are aged 18 years or above. Yes No Your children's details How many children under the age of 18 do you have? * Select how many children under 18 years old you have. Select how many children under 18 years old you have. 1 2 3 4 5 6 First name of child 1 * Enter your first child's first name. Surname of child 1 * Enter your first child's surname. Date of birth of child 1 * Enter your first child's date of birth using the format dd/mm/yyyy. First name of child 2 * Enter your second child's name. Surname of child 2 * Enter your second child's surname. Date of birth of child 2 * Enter the date of birth of child 2 in the format dd/mm/yyyy. First name of child 3 * Enter the first name of your third child. Surname of child 3 * Enter the surname of your third child. Date of birth of child 3 * Enter your third child's date of birth using the format dd/mm/yyyy. First name of child 4 * Enter the first name of your fourth child. Surname of child 4 * Enter the surname of your fourth child. Date of birth of child 4 * Enter your fourth child's date of birth using the format dd/mm/yyyy. First name of child 5 * Enter the first name of your fifth child. Surname of child 5 * Enter the surname of your fifth child. Date of birth of child 5 * Enter your fifth child's date of birth using the format dd/mm/yyyy. First name of child 6 * Enter the first name of your sixth child. Surname of child 6 * Enter the surname of your sixth child. Date of birth of child 6 * Enter your sixth child's date of birth using the format dd/mm/yyyy. The following questions are not mandatory, but any information you provide will help us to best meet your needs. This question is about gender identity. Do you identify as: Let us know your gender identity. Female Male Transgender woman Transgender man Intersex Other Prefer not to say If other gender identity, specify here. If you have answered 'Other gender identity', let us know how you identify. Which of the following best describes your sexual orientation? Let us know your sexual orientation. Straight (heterosexual) Gay or lesbian Bisexual Other sexual orientation If other sexual orientation, please specify. If you have answered 'Other', please let us know your sexual orientation. What is your ethnicity? Let us know your ethnic background. Select your ethnic background. Asian British Bangladeshi Black African Black Caribbean Black British Chinese Indian Pakistani Traveller (Irish) Traveller (Romany/Gypsy) White & Asian White & Black African White & Black Caribbean White British White Irish Not known Prefer not to say Other If other, please specify. If you have answered other, please let us know your ethic background. What is your religion? Let us know your religion. Select your religion. No religion Christian (including Church of England, Catholic, Protestant and all other Christian denominations) Buddhist Hindu Jewish Muslim Sikh Any other religion If any other religion, please specify. If you follow any other religion or faith, please let us know, Is English your first language? Let us know your first language. Yes No What is your first language? Let us know what your first language is. Do you require an interpreter? Tell us if you need an interpreter. Yes No Other help you may need to use our services Let us know about any disabilities or needs you might have to access our services. Person causing harm details Title Select the persons title. Select an option Mr Mrs Miss Ms Mx Dr Other Other Enter the person's title if it is not listed above. First name * Enter the persons first name. Last name * Enter the persons last name. What is their date of birth? * Enter their date of birth in the format DD/MM/YYYY, for example 01/01/1901. Relationship to you * Enter the person's relationship to you. Status of relationship Enter the status of their relationship to you, for example, ex-partner. The following questions are about your circumstances and the help you need. Let us know about your current situation - select all of the below that apply to you. Select all of the situations that apply to your current circumstances. I am currently very frightened There has been an incident that has resulted in a physical injury There has been an instance of abuse in the last 3 months The person is very controlling or jealous The person has previously tried to strangle, choke, suffocate or drown me I am worried I might be experiencing abuse There are child custody issues between myself and the person Tell us more about your situation. Let us know more about the background and circumstances what is happening to you. Are you receiving any support? Let us know if you are receiving any support from organisations, professionals, friends or family members. This is to help us understand whether we can work with others to help you. What types of support are you looking for? Select all types of help you need. Help to keep myself or my family safe Help to report abuse to the police Help to understand my experiences Information and support about my housing situation Information and support about family court Information and support about helping my child or children
