I am fleeing domestic abuse or other violence

Fields marked with * are required
Data Protection and Confidentiality Statement
1. Completing this online advice form will lead to your personal information being processed by the Triage team for the purpose of assisting with your housing enquiry and related issues.
  
  You may also be advised to contact other services within Breckland council or to contact external organisations who may also collect and process your personal data subject to their own privacy policies.
  
  This may include:
  
  Processing of personal data by Breckland Council for the purpose of providing housing advice, including checking information provided with your landlord, doctor, hospital consultant or other external agencies
  
  Secure storing of the information as outlined in the Housing Privacy Notice
  
  Secure storing of the information as outlined in the Community Privacy Notice
  
  Even if you are advised to contact other services within Breckland council or to contact external organisations, all form submissions will be sent to the Triage team (with the exception of condition of property issues which are directly signposted to our Private Sector Housing Team). This ensures the Triage team are aware of your enquiry, and you receive services that meet your needs.
  
  Please review our Housing Privacy Notice and Community Privacy Notice for information on how the Housing team and Triage team uses and stores your data.
  
  Please tick the box below to confirm that you have read and understood the above statement and that you have read the Housing Privacy Notice and Community Privacy Notice.
2. I confirm that I have read and understood the above statement and that I have read the Housing Privacy Notice and Community Privacy Notice and I understand that by ticking the declaration box below it is classed as my electronic signature and is the legally binding equivalent to my handwritten signature. *
Danger layout
1. Are you in immediate danger?*
  
  Yes
  
  No
Indanger
1. If its an emergency please contact 999 and only submit this form when it is safe to do so.
Domestic abuse is any incident or pattern of controlling, coercive, threatening, degrading, or violent behaviour—including physical, emotional, psychological, sexual, or economic abuse—by a partner, ex-partner, or family member, regardless of gender or sexuality.
What type of abuse are you fleeing?*
1. Domestic abuse (this includes physical, coercive and mental abuse)
2. Other forms of violence/harassment

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I am fleeing domestic abuse or other violence

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I am fleeing domestic abuse or other violence

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