DownloadsWho’s the service for?

  • Women who may have been victims of domestic abuse or at risk of domestic abuse
  • Women offenders, those at risk of offending
  • Women in need of accommodation

Advisory: We require detailed information and as a result the form is unavoidably long.

Please Note: All details submitted are held in the strictest confidence, and are only shared with any third parties in certain circumstances. See our privacy policies here.
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Click to Download Referral Form

Download the Word version or complete and send the secure form below:

Introduction:

  • Please see the guidance notes below and complete the form as best you can. This form will be sent to our support team via operationmanager@waitsaction.org.
 

Data Protection & Confidentiality Agreement:

  • The purpose of this section is to ensure that WAITS is able to obtain and share information about you, as necessary.
  • WAITS will treat your information as confidential, and will store your information in accordance with the Data Protection Act (1998). There are some exceptional circumstances however, when we would breach confidentiality WITHOUT your consent. These include: • Where there is a risk of serious harm to yourself. • Where there is a risk of harm to others. • Where there is a risk of a serious crime being committed.
 

My Details:

 

What type(s) of support do you require?

  • If our service is appropriate then we will arrange to interview the client with 5 days and we will advise you how long we anticipate before your client can access our service.
  • Occasionally we may have no suitable vacancies. In these circumstances, applicants will be placed on a waiting list.
 

Employment & Benefits Information:

 

Housing Information

 

Dependants

    Important: You must use one of the following 2 options

 

Refuge Information: (only if seeking refuge) otherwise you can skip to the next section!:

 

Offending Profile:

  • If “Yes”, continue with OFFENDING HISTORY section, if “No”, go to VERIFICATION below and complete this referral form.
 

Offending History:

  • Please mark all offence types for which you have been convicted.
 

Re-offending & Bail Conditions:

 

Risk Profile

  • Summary

  • Thank you for completing this form.
 

Verification

What will happen next?

Once the referral form and risk profile has been received we will contact you within 5 working days to discuss the referral with you and advise you if your client is eligible for our service.

If our service is not appropriate for your client we will advise on alternative services.

If our service is appropriate then we will arrange to interview the client with 5 days and we will advise you how long we anticipate before your client can access our service.

Occasionally we may have no suitable vacancies. In these circumstances, applicants will be placed on a waiting list.