Self Referral Form

Emergency Safety Info

If you are in immediate danger:

Call 999 (Police)
Free 24hr National Domestic Abuse Helpline: 0808 2000 247

Your details

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Thank you for your response. ✨

Your Full Name

Date of Birth

YYYY-MM-DD

Email Address

Phone Number

Choose one option(required)

Yes No – please read the note below

If it is not safe to contact you directly, please let us know how we can reach you safely in the additional notes section below.

Preferred method of contact(required)

Phone call Text / WhatsApp Email

Best time to reach you(required)

Morning (9am – 12pm) Afternoon (12pm – 5pm) Evening (5pm – 7pm)

Your address

Address Line 1

Address Line 2

Town/City

County

Which support programmes are you interested in?

Wellbeing Workshops – Safe space for healing, self‑esteem, coping skills & peer support

Parenting Workshops – Parenting styles, positive behaviour management, building children’s confidence, share experiences & get peer support

Healthy Relationship Programme – Healthy/unhealthy patterns, communication, boundaries, attachment styles & safety

How did you hear about us?

Domestic Abuse Support Clinic – Confidential advice, safety planning, signposting & referrals to specialist services

Postcode

Consent & Information Sharing

I consent to Catch Em CIC storing and using the information I have provided to assess my suitability for their programmes and to contact me about my referral.

I understand that my information may be shared with relevant partner agencies where necessary to safeguard my wellbeing or meet a legal duty to share.

I confirm that the information I have provided is accurate to the best of my knowledge.

Tell us a little about what you are looking for support with

Is there anything else you would like us to know?

Known Additional Needs

Mental health / trauma

Disability / long‑term health

Financial / housing / legal

Child protection / care duties

Substance misuse

Other – please specify

Data protection & confidentiality: Information shared in this form is handled in line with data protection laws and our safeguarding policy. We only collect details that help us assess suitability for our programmes and plan safe, trauma-informed support. Your referral will be treated as confidential and shared only with relevant Catch Em CIC team members or safeguarding partners where there is a risk of harm or legal duty to share.

What happens next?

Once you submit this form, a member of the Catch Em CIC team will be in touch with you to have a gentle conversation about your needs and explore which of our programmes may be the right fit for you. There is no pressure — we will go at your pace.

If you would like to find out more about what we offer before submitting, you are welcome to explore our services or get in touch with any questions.