Domestic Abuse Fire Safety Referral

Agency*

Niche reference number (If known)

Name of person making referral*

Contact number of person making referral*

Contact email address of person making referral*

Reasons why permission has not been given*

What was the reason for the referral?*

Details of person requiring a visit

Title*

Contact Number*

Including area code if land line

Preferred method for first contact

When is the best time for us to attempt contact with this person*

This will help us decide on the best course of action

When is the best time for us to visit this person*

This will help us decide on the best course of action

Are you aware of any potential risks to NYFRS staff if they visit the property?

Domestic Abuse Fire Safety Referral Form