Self Referrals Fields marked with a * are required. To get help from the DAP please fill out this form. The DAP will be in contact with you as soon as possible, though we are not an emergency service. Your contact details (please only enter telephone numbers and emails which are safe for us to contact, you can write in the fields ‘unsafe’ or ‘no details’ as/if appropriate) Your name (or preferred name) * Your email address * Is it safe for us to contact you at this address? Only tick this box if we can safely write to you at this email address regarding your referral Your telephone number * Is it safe for us to call you on this number? When is it safe for us to call? Your address Your date of birth * Monitoring information: Your age group (select one) * Under 16 16-17 18-24 25-34 35-44 45-54 55-64 65+ Prefer not to say How would you describe your gender? * Do you identify as a trans person or somebody with trans history*? (select one) Yes No Prefer not to say Unsure Are you intersex? (select one) * Yes No Unsure What pronouns would you like us to use when communicating with you? (select one) * He She They Other (please state below) If you selected other above please specify here: How would you describe your sexual orientation? (select one) * Lesbian Gay Bisexual Queer Questioning Heterosexual Other Would you describe yourself as having a disability or life long illness (if you have more than one please select the one that has the greatest impact on your life)? (select one) * Blind or visual impairment Deaf or hearing impaired Learning difficulty Mental health Mobility Other disability Prefer not to say I have no disability Ethnic background (select one) * Asian - Bangladeshi Asian - British Asian - Indian Asian - Pakistani Asian - Other Black - African Black - British Black - Caribbean Black - Other White - British White - Irish White - European White - Other Other - Chinese Other - Latin American Other - Middle Eastern Other - Mixed ethnicity Other - prefer not to say Do you have a religion or belief? (select one) * Agnostic Atheist Bahai Buddhist Christian Hindu Humanist Jain Jewish Muslim Rastafarian Sikh Zoroastrian Not religious related to sexuality / gender identity Not religious general Prefer not to say What part of London are you from? (select one) Barking and Dagenham Barnet Bexley Brent Bromley Camden City of London Croydon Ealing Enfield Greenwich Hammersmith Hackney Harringey Harrow Havering Hillingdon Hounslow Islington Kensington and Chelsea Kingston upon Thames Lambeth Lewisham Merton Newham Redbridge Richmond upon Thames Southwark Sutton Tower Hamlets Waltham Forest Wandsworth Westminster Reason for the referral: Tell us about your situation (if you can, please provide the name and / or date of birth of the perpetrator) * Tell us about what support you think you need to help you get back on track? * I agree to this information being shared with other DAP partners (e.g. if you need housing advice or counselling) * If you have anything you would like to add or any feedback on this form then please provide it here: ------------------------------------------------------------------- ONLY COMPLETE THE FOLLOWING SECTION IF YOU ARE A PROFESSIONAL REFERRING A CLIENT Does the client know you are referring to DAP? (select one) Yes No Name of practitioner Referring organisation Reason for referral Phone number Email If you are a human and are seeing this field, please leave it blank.