Self Referral Form "*" indicates required fields CommentsThis field is for validation purposes and should be left unchanged.Use this form is you would like to refer yourself to any of our services. If you are applying on behalf of a client, please complete our Agency Referral Form. If you have any questions about the application process please call us on 01273 612025 or email hello@lotus-families.org.uk Referral details:Type of service*To help us provide you with the best possible support, we offer one service at a time. Please choose the service that feels most important to you at the moment. Once that support has concluded, we can talk with you about whether another of our services may be helpful. Domestic abuse victim/survivor over 16 Parent experiencing abuse from a child (aged between 8 and 17) Trans and Non-Binary IDVA Service Please let us know why you are making a referral. Include any safety concerns you have for yourself or your family.*Please contact Advance (East Sussex) 0330 055 9278 or Victim Support (Brighton & Hove) on 0330 055 9278 or 08 08 16 89 111 (out of hours) if you are currently experiencing abuse from a partner or ex-partner.Your details:Fields not marked with an asterisk are optional. This data is collected for equalities monitoring purposes only.Name* First Last Date of Birth* Day Month Year AgeSex at birth* Male Female Preferred pronounsIdentifies as transgender or non-binary? Yes No Gender if different from sex at birth:Address* Street Address City ZIP / Postal Code Safe contact number*Safe email* EthnicityReligionPrimary Language*Is an interpreter required?* Yes No How did you hear about us?Do you have any disabilities / literacy issues* Yes No You said 'Yes'. Please provide details*Sexuality Heterosexual Gay Lesbian Bisexual Other How many children do you have under the ages of 18*012345678910Child 1 - date of birth* Day Month Year Child 2 - date of birth* Day Month Year Child 3 - date of birth* Day Month Year Child 4 - date of birth* Day Month Year Child 5 - date of birth* Day Month Year Child 6 - date of birth* Day Month Year Child 7 - date of birth* Day Month Year Child 8 - date of birth* Day Month Year Child 9 - date of birth* Day Month Year Child 10 - date of birth* Day Month Year Subject to Child Protection Plan?* Yes No Currently pregnant?* Yes No Other support needs? Drugs Alcohol Mental Health Other Support in place from other services?* Yes No Δ Getting HelpClient Stories Self Referral Form Agency Referral Form Referrals Donate(opens in new tab)
