This referral has NOT been sent yet. You will be redirected to the listing's external referral form. Please complete the referral form there to submit the referral confirm Details The Alessia Project by Hestia Who is this referral for? I am signing up myself I am referring someone else Service access criteria Tick to confirm you have checked the service access criteria "Living or working in Newham" Your Details Email Email is invalid We already have an account with this email. Please log in. Password Reset my password Log in First name Last name Your relationship to the person Organisation name Who are you referring? First name Last name Known as Date of birth Email Don't know / client doesn't have an email address Phone Address Line 1 Address Line 2 Town/City Postcode GP surgery Ethnicity SelectEnglish, Welsh, Scottish, Northern Irish or British Irish Gypsy or Irish Traveller Any other White backgroundWhite and Black Caribbean White and Black African White and Asian Any other Mixed or Multiple ethnic backgroundIndian Pakistani Bangladeshi Chinese Any other Asian backgroundAfrican Caribbean Any other Black, African or Caribbean backgroundArab Any other ethnic groupPrefer not to say Gender SelectFemale Male Transgender female Transgender male Non-binary Intersex Not specified Not known Other Additional referral details Do not enter protected health information (PHI) or any other personal data in these fields. Should the service provider be aware of any additional needs? Blind/partially blind Memory problem Hearing loss Housebound Does not speak English Poor mobility Learning and communication needs Physical disability Frail Other: Safe telephone number to contact Is it safe to leave a voicemail or send a text? Yes No Other: Alternative telephone number Is the address above safe to write to? Yes No Other: Is the email address above safe to write to? Yes No Other: What is their immigration status? Do they have a disability? Languages spoken Religion Sexual orientation Please list their children's names, genders, ages, their relationship to them, whether or not they have parental responsibility and their schools Are they pregnant? If so, what is the due date? Is this a high risk with RIC 14+ referral? Yes No Are there any child contact issues? Code word / safe time to call Reason for referral - please include details of incident prompting referral, any history of violence experienced, any police call outs, A&E attendances, injuries and child witnessing Types of abuse experienced Physical Emotional Sexual Economical FGM Sex work Verbal Coercive behaviour Honour based violence Other: This field is required. Significant / known risk factors (e.g. staff safety issues, serial / repeat perpetrator, suitable times to call, suicide, self-harm, MARAC case, risk from family members / strangers) Please indicate client support required in the following areas: mental health Mental health issues Diagnosis Treatment This field is required. Please indicate client support required in the following areas: employment Unemploted Employed In education / training This field is required. Please indicate client support required in the following areas: substance use Drugs Alcohol Treatment This field is required. Please indicate client support required in the following areas: housing homeless perp remains in property Insecure housing This field is required. Please indicate client support required in the following areas: other Literacy or numeracy needs Criminal justice / court proceedings Insecure housing This field is required. Describe relationship and living arrangements Confirmation and consent Tick to confirm you have gained consent to share this information with the service provider, your organisation and Joy Tick to confirm the service provider can directly contact the client Would you like to create an account? Make referrals faster next time you use Joy. Registered users can message service providers, submit reviews and track the progress of their referrals online. Password Weak password! Use at least 8 characters Use upper and lowercase characters (a-z) Use 1 or more numbers (0-9) Confirm password Please enter the same value again. required Submit Email: Password: Email
