Referral Form

Jubilee House aims to acknowledge and triage all referrals within 48 working hours of receipt. Our opening hours are 9:30am - 5pm Monday - Friday. We are closed on bank holidays and the final 2 weeks in December.

If there is immediate risk, please phone 999.

For out of hour domestic abuse support please phone the National Domestic abuse and Forced Marriage helpline on 0800 027 1234.

Are you making this referral for yourself or someone else?*

Myself

Someone Else

Client Details

First name*

Last name*

Date of Birth*

Day

Month

Year

Address*

Is it safe to write?*

Yes

No

Phone Number*

Is it safe to phone/text/leave a message?*

Yes

No

Email

Is it safe to email?

Yes

No

Please list any other agencies involved

Please enter the name/s, DOB and addresses of any children/dependents *

CYPS Involvement?

Yes

No

Translator required?*

Yes

No

If yes, please specify

Equalities Monitoring

Disability

LGBTQ+

B+ME

Reason for referral*

Please provide any information that may assist us in determining the urgency and priority of this referral, including any recent escalation in abuse, safeguarding concerns, significant changes in circumstances, or other factors that may increase risk.*