Get in Touch with alchemHer CIC

hello@alchemher.com

Registered Office Address

AlchemHer CIC
London – Mayfair
3rd Floor
45
Albemarle Street, Mayfair
W1S 4JL

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Get Support Safely: AlchemHer CIC Referral Form

This form is for women self-referring and for professionals making referrals to AlchemHer CIC.
We provide post-separation domestic abuse recovery, emotional support, trauma-informed guidance and community programmes for women aged eighteen and above.
All information is confidential and handled in line with our safeguarding and data protection policies.

Referrer Name (optional)

Enter your name if you are a professional referring.

This field is required.

Organisation (optional)

Enter your organisation's name if applicable.

This field is required.

Referrer Email (optional)

Your email address for further contact.

This field is required.

Referrer Phone (optional)

Your phone number (optional).

This field is required.

Full Name

Enter the full name of the person being referred.

This field is required.

Preferred Name (optional)

Enter the preferred name if applicable.

This field is required.

Age

Enter the age of the person being referred.

This field is required.

Location (Town / Country)

Enter the location of the person being referred.

This field is required.

Safe Email Address

Enter a safe email address for the referred person.

This field is required.

Safe Phone Number

Enter a safe phone number for the referred person.

This field is required.

Brief description of any safety concerns

Provide a brief description of any safety concerns.

Reason for referral / What support is needed?

Explain the reason for the referral and what support is needed.

Type of support requested

Select the type of support requested.

I confirm I consent to AlchemHer CIC contacting me (or the woman being referred) using the provided safe contact details.

Consent to contact using safe details.

This field is required.

Anything else we should know?

Provide any additional notes that may be helpful.