Halo Project

Referral Form

Please note that our outreach support services are available in Teesside, Darlington, Durham, and North Yorkshire, if you require information, advice and guidance from an area outside our coverage please contact our helpline at 01642 683045 where our dedicated team is ready to assist you regardless of your location. Halo Homes refuge is located in Teesside providing safe and secure temporary accommodation for women and children who have been victims of domestic abuse.

Referrer Details

Client Details

Which or these contact methods are safe to use? *
Is it safe to leave voicemail message/text? *

Marriage Details (if applicable)

General Information

Interpreter Needed *
Do you receive benefits?

Immigration Status

Indefinite Leave to Remain *
Recourse to Public Funds

Perpetrator Details (if applicable)

Perpetrator 1

Perpetrator 2

Children Details (if applicable)

Child 1 Details

Child 2 Details

Child 3 Details

Child 4 Details

Child 5 Details

Children Details (cont.)

Are you pregnant?
Was a child present at the incident?
Did the child witness the incident?

School Details

Details of Problem/Enquiry/Reason for Referral

Referred to MARAC?

Safe Person To Contact

Risk Assessment — Refuge

What issues do you need support with?

Client Authorisation