Refuge Referral Form

Please Fill in the form Below

How to complete this referral:

By completing this referral form, you’re helping us to contact the client as safely and quickly as possible. We’d appreciate it if you could include as much information as possible – this saves the client from being asked the same questions twice and helps us to understand more about their needs and circumstances.

Eligibility criteria for this service:
Please be sure to check that the client meets the following criteria before making the referral:

All PDAP accommodation is for any women aged 16 or above with or without children fleeing domestic abuse.

Accompanying documents:

Please attach the following documents to this referral, if completed:

  • Recent DASH risk assessment (if one has been done)
  • Proof of immigration status or recourse to public funds. How to get in touch:If you have any questions about our service, eligibility criteria, or how to make a referral, please contact PDAP’s 24 hr Helpline 0800 052 7222

Alternative Form Download

If you do not wish to fill in the form below you can download the form and print it off and send it back to us by post.

Simply hit the button below to download the paper version of our form and fill in as much information as possible and send it back to us.

Download Refuge Form

Page 1 of 8

1. Information about the person making the referral

Please enter your name and contact details

2. Client contact info

Next of kin – who can we contact in an emergency?

Accessibility requirements

3. Client equalities monitoring

4. Client support needs vulnerabilities

5. Children

If the person being referred has children, please provide their names and DOBs below:

6. Alleged perpetrator/s

Information about the alleged perpetrator, if known:

7. Reason for referral

Accompanying documents

Please attach the following documents to this referral, if completed: