Professional
referral form

By completing this form, you’re helping us to make contact with our customer as safely and quickly as possible. It is important to include as much information as you can. We will only accept referrals where the customer is aware and has consented to this referral being made on their behalf.

*** Availability of service over the holiday season ***

Please be aware that Amplius will be closed at 5pm 24 December 2024 until 2 January 2025.
No referrals will be actioned until the organisation reopens in the New Year.
Throughout this period, in an emergency situation, please call 999 for help.
All safeguarding referrals should be completed as soon as possible by contacting the relevant local authority Social Services.

The National Domestic Abuse Helpline is a 24 hour service which can be contacted by women seeking support on 0808 2000 247.
Respect  – Support for men – contact 0808 8010 327 National Helpline for LGBT+ Victims and Survivors of Abuse and Violence 0800 999 5428

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Professional referral form

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