Self-referral form


Please be aware that Grand Union will be closed at 5pm Thursday 28 March. No referrals will be actioned until the organisation reopens on Tuesday 2 April 2024.

Throughout this period, if you require emergency assistance, please call 999 for help. All safeguarding referrals should be completed as soon as possible by contacting the relevant local authority Social Services.  For refuge accommodation and/or advice please seek support by calling

Please complete the form below and ‘Submit’ after completion. The form will be sent to the Grand Union Domestic Abuse and Safeguarding Team. Once received, a colleague will make contact to discuss your concerns and how best we can help you. We will be able to provide information about services in your area and discuss all options available to you, for you to make the best decision for yourself. Unfortunately we are only able to provide this service to Grand Union customers.