Personal referral form - Veritas Justice

Self referral

Step 1 of 12

Your details

Date of referral(Required)

Day

Month

Year

Full Name(Required)

First Last

Aliases

Other names used or nicknames, etc.

Date of birth(Required)

Day

Month

Year

Are there any communication support needs?(Required)

Communication support needs.(Required)

Please provide as much detail as possible, for instance hearing, sight, interpreter requirements, neuro-diversity requirements, for example dyslexia, dyspraxia, autism etc.

You contact details

Your address(Required)

Street Address Address Line 2 City County Postcode

Is it safe to directly call you?(Required)

Is it safe to directly text or WhatsApp you?(Required)

Your phone number(Required)

Is it safe to directly email you?(Required)

Your email(Required)

Enter Email Confirm Email

How do we make safe contact?(Required)

Should it not be safe to directly contact the person at risk, how do we contact them? Can we contact via any other professionals working with the person at risk or a close family member to facilitate safe contact?

Equality & diversity information

Sex(Required)

Gender(Required)

Other gender(Required)

Transgender(Required)

Relationship status(Required)

Other relationship status(Required)

Sexual orientation(Required)

Sexual orientation other(Required)

Ethnicity(Required)

Ethnicity other(Required)

Religion(Required)

Religion other(Required)

Your disability details

Do you consider yourself to have a disability?(Required)

Your disabilities(Required)

Additional disability notes

Person suspected of stalking

You may add one person – please contact Veritas for further guidance if this is not the case.

Do you know the details of the person suspected of stalking?(Required)

Details of the person suspected of stalking

Name of the person suspection of stalking(Required)

First Last

Aliases of the person suspection of stalking ( if known )

Other names used or nicknames, etc.

Do you know their date of birth?(Required)

Date of birth(Required)

Day

Month

Year

Do you know their current address?(Required)

Address(Required)

Street Address Address Line 2 City County Postcode

Equality & diversity information of person suspected of stalking

Sex of suspect(Required)

Gender of suspect(Required)

Other gender(Required)

Relationship to you(Required)

Children linked to you

Are there any children (under the age of 18 years) linked to you?(Required)

This should include any linked child living with you or elsewhere.

Please add any children

Please add details of any children ( Click plus icon to add more )(Required)

First name

Last name

Approx Age

Relationship to you

* If any details not know, please state that.

Person at risk pregnancy details

Are you pregnant?(Required)

Referral Details

*Please note

Veritas Justice need to contact Sussex Police to support ongoing cases.
Without authorisation, we will only be able to offer you a one-off safety planning appointment.

Do you authorise Veritas Justice to contact Sussex Police about your case(Required)

Is your referral for ongoing support?(Required)

Is there an active stalking investigation with Sussex Police?(Required)

Do you have Crime Reference Number (CRN )(Required)

Please enter the Crime Reference Number (CRN)(Required)

Why do you not have the Crime Reference Number (CRN)

Have you spoken / reported to any other agency?(Required)

Which agency have you spoken / reported to?(Required)

Has the suspected stalker been arrested in this case?(Required)

If the suspected stalker was charged, do you know what were they charged with?(Required)

* Please include any crime reference number (CRN) and investigating officer details here. If details unknown, please state that.

Are there any police bail conditions?(Required)

If the suspected stalker was given bail conditions by the police, what were they?(Required)

* If the bail conditions are unknown at present, please state that.

Is there a local Domestic Violence service assisting you?(Required)

If you are being supported by a Domestic Violence service, please state which one.(Required)

* If the service is not known please state

Do you know if the suspected stalker attended court?(Required)

If the suspected stalker has attended court, please detail below details of the charges, bail conditions, next court hearing date and any other relevant information:(Required)

* If unknown at present, please state that.

Additional referral details

Please enter at least two incidents of stalking behaviour within the last 6 months?

First incident of stalking behaviour within the last 6 months?(Required)

Approx date

Incident details

Please give basic information about what you have experienced - use the box below if you would like to give more information about the incidents.

Second incident of stalking behaviour within the last 6 months? ( Click plus icon to add more )(Required)

Approx date

Incident details

Please give basic information about what you have experienced - use the box below if you would like to give more information about the incidents.

More incident information

Please select any of the stalking behaviours that you have experienced(Required)

Texts

Calls

Direct messages

Social media

Gaming platforms

Threats

Following

Attending ( Home / Place of work or study )

Tracking & surveillance

Unwanted gifts

Other ( Please list below )

Tick as many as necessary

Please add any further information that you think will assist us in triaging this referral.