Self-referral form

Please complete the form below and ‘Submit’ after completion. The form will be sent to the Amplius Domestic Abuse and Safeguarding Team. Once received, a colleague will make contact to discuss your concerns and how best we can help you. We will be able to provide information about services in your area and discuss all options available to you, for you to make the best decision for yourself. Unfortunately, we are only able to provide this service to Amplius customers.

*** 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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Self-referral form

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