Self Referral Form

Self-refer to Safe Steps

Support from our Adult Services (Dove)

Contact Essex COMPASS, the domestic abuse helpline, on 0330 333 7 444 or self-refer online at www.essexcompass.org.uk/self-referral

When COMPASS have received your self referral, a member of staff will give you a call to complete an assessment and this will give you the opportunity to ask any questions about the service and to help you decide about the type of support you would like to receive. We use a translation service for those who may need it.

Support from our Children and Young People’s Services: self-refer using the below form.

Refuge: call 01702 302333 Monday-Friday (9am-5pm) or Essex COMPASS on 0330 333 7 444 (8am-8pm weekdays and 8am-1pm weekends).

Name (Parent / Guardian)
First Last
Nickname / any other name you use
Gender*
Date of birth*

Day
Month
Year
Postcode
If you live outside of Southend but still in Essex, please go to Essex COMPASS to self refer.
Email address
Safe to send an email?
- Yes
- No
Phone number*
Safe to call, leave a voice message & send texts?*
- Yes
- No
Other preferred contact method
What services do you require?*
Please enter any comments below
I confirm that I am submitting this referral on behalf of myself and not for another person. By submitting this referral, you are consenting to being contacted by a practitioner*
- Yes
Where did you hear about this website?
Email
This field is for validation purposes and should be left unchanged.