Agency Referral Form for Survivors’ Network

If you are a survivor and would like to refer yourself for support, please click here

We have closed the following Counselling waiting lists for:
Adults in Brighton and Hove
Young People in East Sussex
Please see the about/news and blogs section on our website for more details

You can use the form below to refer people that you are working with for support with their experience of sexual violence and abuse.

Survivors’ Network offers advice, support and information to:

  1. People who live in Sussex. We will support some clients living outside of Sussex who are giving evidence in court here, on a discretionary basis. We also will support clients who experienced sexual abuse in the Diocese of Chichester.
  2. People of all genders, though some of our services are for self-identifying women only.
  3. People who have experienced some form of sexual violence or abuse in their lives.
  4. People who consent to being contacted by us to discuss their support options in relation to their experience of sexual violence/abuse specifically
If you are unsure if your referral is suitable or have any further questions please contact us on 01273 203380 before completing this referral form.

Before you refer

  • If you are making a referral for someone who has been assaulted within the last 7 days and it is outside of office hours and/or a forensic and health consultation may be of benefit, please contact the Saturn Centre on 0800 033 7797.
  • If the person you are referring has recently experienced or is currently experiencing domestic violence please confirm that you have also referred into domestic violence services and completed all necessary safeguarding referrals (including MARAC referrals if appropriate). We need this to be completed before we process the referral.
  • If the person you are referring has any other safeguarding needs, please ensure that appropriate action is taken prior to referral.

Information submitted on this referral form will be treated as confidential and stored securely on the Survivors’ Network data management system. Information is only shared with third parties with the explicit consent of the person being referred or if there is a risk of significant harm or safeguarding concerns.

Anti-bullying and Anti-harassment statement

We are committed to providing a workplace where all employees are treated with dignity, courtesy, and respect. As part of our Anti-Bullying, Anti-Harassment, and Sexual Harassment Policy, we maintain a zero-tolerance approach to any form of bullying, harassment, or discriminatory behaviour toward our staff. This includes conduct by customers, clients, contractors, suppliers, or any third parties.

Please tick this box to confirm that that you accept the above and that the individual below has consented for this referral.*

Referrer details
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Essential details
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Client contact details
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If a child/young person referral, state relationship

If a child/young person referral, state relationship

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Additional details
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Does the referee identify as trans or having a trans history?
Select as many relevant.
Select as many relevant.
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Select as many relevant.
To expand, pull the bottom right of input box.
Please provide an explanation for the reason for this referral.*
Include information on:
  • Which services you are referring into:
    • Trauma Sensitive Yoga
    • Create & Connect group
  • Peer Support Group – please specify the name of the group
    • Maple
    • Cedar
    • Aspen
    • Oak
  • Adult Independent Sexual Violence Advisor (ISVA)
    • Please note that our ISVA service can only support crime types for rape or serious sexual offences, including attempts or sexual abuse in childhood.
    • Young Peoples Groupwork
    • Child, or Young Persons ISVA
  • Any safeguarding or risk concerns.
  • Any specific concerns over the safety of the survivor in the last 6 months.
    • Please note if there is a Domestic Abuse risk this will need to be referred to your local Domestic Abuse service.
To expand, pull the bottom right of input box.
Dependants

Any children and any adults who are dependent on your care

Dependant 1
Dependant 2
Dependant 3
Contact details of any professionals involved

Assault details (if known)
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(CSA means 'Childhood Sexual Abuse') Choose most relevant category
Consent is required