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Devon Referral Forms

If you would like to complete a full referral form rather than the initial online form then use the form below.

Devon Adult Referral Form

Submit the form by email or fax.

Fax: 01392 368071

Email using secure email to: This email address is being protected from spambots. You need JavaScript enabled to view it.*

* you cannot send a secure email to this email address unless you have a secure email account that has access to the CJSM secure email system

Data Protection

Privacy

We need to collect and process your data to help us provide a service to you. We may ask for details about your children and other family members who may also need support.

We may ask for data about your ethnicity, religion and sexuality. However, this data will only be used for statistical purposes only.

We do not use any automatic processing to determine the support we offer. You will be supported according to your needs and according to your wishes.

Some information you provide will be used to help us to improve our services.

Sharing

We will not share your information with other people or agencies without your permission, unless required to do so by law, or where there is a risk to you or others.

Your rights

You can ask us for a copy of the data we hold about you, or ask us to edit the data we hold about you to ensure it remains accurate.

Referral Forms

Phoenix Self Referral Form

Phoenix Professional Referral Form

Use this form to access our domestic abuse and sexual violence services in Wiltshire and Swindon.

PRG Referral Form
Use this form to access our domestic abuse programmes in Gloucestershire.

Splitz Support Service, Oak House, Epsom Square, White Horse Business Park, Trowbridge BA14 0XG
Registered Charity No: 1064764; Registered in England, Company Limited by Guarantee No: 3360057
Copyright © 2011-2019 Splitz Support Service. All Rights Reserved.

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