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Contact Us
Family Intervention Counselling Service (FICS)
Home
About Us
What We Do
Outcomes
Current Projects
Our Team
NEWS
GDPR
Training and Volunteering Opportunity
Where else can I get help?
Reporting domestic abuse & Court Orders
Complaints Policy
Modern Slavery Statement
Self Referral Form
Professional's Referral Form
Professional's Victim Referral
Professional's DAPP Referral
Contact Us
Please complete this form to make a self referral. We will contact you once we receive your form, if we have not contacted you within 3 days please contact-
admin@interventionservice.co.uk
Your details
Name
*
First Name
Last Name
Date of Birth
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What is your gender?
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What is your sex?
*
Female
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What is your sexual orientation?
*
Heterosexual
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Other
Prefer not to say
Unknown
What is your ethnicity?
*
White: British, English, Welsh, Northern Irish or Scottish
White: Irish
White: Gypsy or Irish Traveler
White: Other
Mixed/Multiple Ethnic Groups: White & Black Carribbean
Mixed/Multiple Ethnic Groups: White & Black African
Mixed/Multiple Ethnic Groups: White & Asian
Mixed/Multiple Ethnic Groups: Other
Asian/Asian British: Indian
Asian/Asian British: Pakistani
Asian/Asian British: Bangladeshi
Asian/Asian British: Chinese
Asian/Asian British: Other
Black/ African/ Caribbean/ Black British: African
Black/ African/ Caribbean/ Black British: Caribbean
Black/ African/ Caribbean/ Black British: Other
Other Ethnic Group: Arab
Other
Prefer not to say
Unknown
What is your nationality?
*
UK
Non-UK
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Unknown
What is your religion?
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No Religion
Prefer Not To Say
Other
Sikh
Muslim
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What is your marital status?
*
Married/Civil Partnership
Co-Habitating
Single
Separated
Divorced/Legally Dissolved Partnership
Widowed
Prefer not to say
Unknown
Do you have a disability?
*
Yes
No
Prefer not to say
Has domestic abuse been reported to the police?
*
Yes
No
Unknown
Have you got any convictions/cautions/warnings?
*
Please give details
Have you ever had problems with being violent, or aggressive towards others?
*
Please give details
Which service would you like to refer into?
*
Adult referral for victim
Adult referral for DAPP
Please state what you hope therapy will achieve:
*
Do you have any additional information you would like to share?
Thank you!