Lotus Justice & Support Centre

Request help

Complete the form below. All fields marked * are required. Your referral is confidential and will be read by Otilia Mutu, qualified IDVA.

If you are in immediate danger, do not fill in this form — call 999.

Continuing a saved form?

1

Who is completing this form?

Select an option (required)
1

What type of help are you looking for?

Select all that apply.

Type of help (required)
2

Your situation

How urgent is this? (required)
How do you feel about your safety?
3

Who is filling in this form?

This form is being filled in by: (required)
4

Personal details

Details of the person who needs help (not the person filling in, if different).

Date of birth*

If it isn't safe to give us your address right now, you can leave these fields empty.

Preferred contact methods (required)

Tell us when it is safe to contact you.

Preferred language for communication (required)
5

Status, benefits and housing

Immigration status (required)
Do you receive state benefits? (required)
Do you receive Universal Credit? (required)
Type of housing (required)
6

Safety questions

These questions help us assess risk and provide the right support.

These questions help us understand your safety and are required. If you are unsure, choose "Prefer not to say". There are no wrong answers, and a full risk assessment will be carried out with an adviser.
1.Has the current abuse worsened or become more frequent recently? (required)
2.Are you very frightened? (required)
3.Have you been strangled/choked or threatened with a weapon? (required)
4.Has the person threatened to kill you or someone else, and did you believe them? (required)
8.Are there children or dependants at risk or harmed? (required)
7

Children and safety

Are there children in the household or involved in the situation? (required)
8

Other professionals involved (optional)

If there are other professionals involved in your case (social worker, GP, etc.), add their details.

These are case contacts, not the person making the referral. They will not receive the email copy.

9

Mortgage

10

Supporting documents (optional)

You can attach up to 6 files (photos, PDFs, Word documents). Maximum 12 MB total. Optionally, you can also add a download link.

Click or drag files here

Photos, PDF, Word — max. 6 files, 12 MB total

11

Declarations and consent

Confidential. Every referral is read by Otilia Mutu, qualified IDVA (Independent Domestic Violence Advocate).

By typing your name you confirm you have read and agree to the declarations above.

Save and continue later

The form will be saved on our server for 7 days. No notification is sent and no reference number is assigned. Nothing is stored in your browser — nothing remains on a shared phone or computer.

Your referral is confidential. Data is processed in accordance with UK GDPR.