Self Referral - Flag DV

Self Referral form

Disclaimer

WE CAN ONLY ADVICE IN MATTERS OF FAMILY LAW. WE CANNOT PROVIDE ADVICE ON CRIMINAL LAW OR IMMIGRATION

Please note this appointment is an ADVICE legal appointment only.

The free legal advice provided by FLAG DV is available only to people experiencing domestic abuse. Domestic abuse is defined as an incident or pattern of incidents of controlling, coercive, threatening, degrading and violent behaviour, including sexual violence, in the majority of cases by a partner or ex-partner, but also by a family member.

Anyone forced to alter their behaviour because they are frightened of their partner’s reaction is being abused.

Our service is for anyone who is experiencing domestic abuse, whether you have left the relationship or are still in it

Based on this information please confirm you are experiencing domestic abuse by indicating what you are experiencing. (You can select more than one)

Emotional Abuse (some examples could be: calling you names, putting you down, intentionally embarrassing you in public, threatening to have your children taken away)Physical (some examples could be: scratching, biting, punching, strangling, throwing things at you)Sexual Abuse (some examples could be: pressuring you to have sex, threatening you with unwanted sexual activity, unwanted kissing or touching, rape of attempted rapeFinancial or economic abuse (some examples could be: preventing you from working, controlling spending, refusing to give money for food or rent, maxing out credit cards without your permission)Coercive Control (some examples could be: unreasonable demands, deprivation of essential needs like food or access to medical, monitoring time, degradation)Stalking (some examples could be: constant unwanted attention or gifts, using technology to keep tabs on you)Psychological (some examples could be: gaslighting, questioning you endlessly over things said, constant name calling, telling you you have mental health conditions you don’t)Online/digital abuse (some examples could be: sending threatening messages through email or social media, looks through your phone frequently without your permission, constantly messages you in a way that causes fear that you will be punished if you don’t reply, posts negative things online about you)

Are you over 18?

YesNo

Our service currently only able to support clients in the following counties, please tick to indicate where you are currently staying:

BuckinghamshireBerkshireOxfordshireHampshireNone of the above

Currently we are not able to accept referrals from other counties. You may find it useful to visit www.lawworks.org.uk as this is a charity who also offer free legal advice. Alternatively, the following services may be of assistance:

https://www.lawcentres.org.uk/i-am-looking-for-advice
otherwise your nearest Citizens Advice Bureau may be able to suggest additional local legal support.

If you are worried for your safety and in immediate danger, please phone 999. If you require the police but it is not an emergency, please ring 101. You may also wish to contact the National Domestic Abuse Helpline on 0808 2000 247.

Currently we are not able to accept referrals from people under 18. You may find it useful to visit www.lawworks.org.uk as this is a charity who also offer free legal advice. Alternatively, the following services may be of assistance:

https://www.lawcentres.org.uk/i-am-looking-for-advice
otherwise your nearest Citizens Advice Bureau may be able to suggest additional local legal support.

Your Details

First Name

Last Name

DOB

Please enter your date of birth in dd/mm/yyyy format

Enter your postcode and click "Find my address"

Address Line 1

Address Line 2

Address line 3

Town

County

Postcode

About your appointment

How we will contact you

Is it safe to contact you directly?

YesNo

Please provide us with a safe way to get in touch with you (eg through a friend or family member). Be sure to include either a phone number or email address in these details. Without these we will not be able to progress your case

Please ensure you provide either a phone number or email

Are you able to supply an email address?

YesNo

Your email address

Your phone number

Is it safe for us to leave a voicemail message?

YesNo

Our admin team needs to have an initial call with you in order to make sure we can match you with the most appropriate solicitor. We make those calls between 10am and 4pm Monday to Friday.

*Please note that we will be able to arrange for your actual solicitor appointment within usual business hours

Please provide the best day/time to contact you for your initial conversation? (we cannot guarantee we can call at this time but we will work hard to make sure it is at a time that is convenient for you)

Do you have any access requirements you would like us to be aware of?

YesNoFor example do you have any particular needs relating to vision, hearing or anything else that we should be mindful of?

Please describe your access needs

Do you need a translator

YesNo

Please indicate what language you require

Please tell us which language you require

Please tell us a little about what you would like to talk to a solicitor about

What is the main area of concern/issues that you would like legal advice on? (you can select more than one) WE CANNOT PROVIDE ADVICE ABOUT IMMIGRATION OR CRIMINAL CASES

Matters relating to your childrenSocial services involvement in your child's case Divorce & separation including civil partnershipAdvice about the legal aid processAdvice about non-molestation orders and/or occupational orders (please note this is advice only, we are unable ensure securing of these orders on your behalf)Property or housing matters arising from your divorce or separationFinancial matters arising from your divorce or separation

What result are you hoping to achieve with a legal advice appointment?

What do you think has been the biggest obstacle in taking legal action?

Unable to afford legal representation	Didn’t qualify for legal aid
Don’t understand my rights	Not ready
Fear	Don’t know how to access help
Other

Please tell us what the obstacles have been

Conflict of Interest Check - The abusers details

In order for our solicitors to provide legal advice they are required to confirm that there is no conflict of interest in doing so.

For this we require the details of the person who has been abusing you.

Without this information we cannot progress your referral as will be unable to confirm we can find a solicitor that can talk with you.

This information will not be used in any way other than to be able to progress your referral with Flag DV

Their First Name

Their Last Name

Their DOB

Please enter their date of birth in dd/mm/yyyy format

What is your relationship to the person abusing you?

Children's details

Are there children between 0-18 involved?

YesNo

Our solicitors also need to ensure there is no conflict of interest with any children involved so again we require the details of the children please.

Without this information we cannot progress your referral as will be unable to confirm we can find a solicitor that can talk with you.

This information will not be used in any way other than to be able to progress your referral with Flag DV

Are you pregnant or the person abusing you pregnant?

YesNo

How many children under 18 are involved?

Details of your first child

Their full name

Their DOB

Please enter their date of birth in dd/mm/yyyy format

Details of your second child

Their full name

Their DOB

Please enter their date of birth in dd/mm/yyyy format

Details of your third child

Their full name

Their DOB

Please enter their date of birth in dd/mm/yyyy format

Details of your fourth child

Their full name

Their DOB

Please enter their date of birth in dd/mm/yyyy format

Details of your fifth child

Their full name

Their DOB

Please enter their date of birth in dd/mm/yyyy format

Details of your sixth child

Their full name

Their DOB

Please enter their date of birth in dd/mm/yyyy format

Details of your seventh child

Their full name

Their DOB

Please enter their date of birth in dd/mm/yyyy format

Details of your eighth child

Their full name

Their DOB

Please enter their date of birth in dd/mm/yyyy format

Details of your ninth child

Their full name

Their DOB

Please enter their date of birth in dd/mm/yyyy format

Details of your tenth child

Their full name

Their DOB

Please enter their date of birth in dd/mm/yyyy format

Almost done! Just a a bit more background information

Do you currently have a solicitor acting on your behalf?

YesNo

What has led to you needing further advice from one of our solicitors?

Have the police ever been involved related to the abuse

YesNo

Are there currently any orders in place?

Non Molestation (family)	Occupation Order (family)
Restraining Order (criminal)	Bail Conditions (criminal)
DVPN (criminal)	DVPO (criminal)
DAPO (family)

Are there expiry dates associated with these orders

Do you have any upcoming court dates

YesNo

What is your upcoming court date?

What is the name of the court where the next hearing is?

If you ever had a solicitor in the past related to this issue what was the outcome?

And lastly - A bit more about you

Your ethnicity

What gender do you identify with?

Your Sexuality

How would you describe your religious affiliation or status?

is there a disability we need to be aware of

None	Physical Disability	Learning Disability
Hearing Disability	Vision Disability	Mental Health Disability
Long Term Condition	Speech Impairment	Disability Unknown

How did you hear about FLAG DV?