Organisation Referral Form

Before you begin completing this online form please note we are happy to answer any questions you may have however, we do not provide a crisis service. In case of an Emergency please call 999.

IMPORTANT PLEASE READ: Before submitting a referral please pay attention to the Information within the Service Details section or take a look at our website ‘Get Help’ tab (all the services we provide), this will help you to refer your client to the correct service/s. If you are unsure about which service to refer to, then please feel free to contact the office on 01325 354 119 or email: info@rsacc-thecentre.org.uk.

We offer free, safe support to anyone over 13 who has experienced any form of sexual violence at any time in their lives.

We can accept referrals from clients who live, work or are accessing education from the following postcode areas: DL1 - DL17, DH1 - DH9, SR7 - SR8, TS21, TS27 - TS29, NE16.

Please note for Durham police referrals please do not use the form below and follow the correct referral pathway.

Please complete the below form with as much information as possible.

We will only accept referrals for those who are aware that the referral is being made.
Please confirm that the person being referred is aware of a referral (tick box)*

Required fields are shown with a *

Referrer Details

Referring Organisation Category*

Referring Organisation*

Referring Organisation Name

Essential Details

Person Making Referral*

Referrers Tel No*

Referrers Email Address*

Client type*

Client First Name*

Client Last Name*

Client Tel No*

Client Email Address

Service Details

Please select one of the options below.

Services

Service criteria /explanation of services (Click here to show/hide details)

Client Contact Details

Address Line 1

Address Line 2

Town*

District*

Postcode*

Permission to Leave Voicemail*

Permission to Send Text*

Permission to Contact via Email*

Permission to send Post*

Alternative Safe Contact Details

Additional Details

Date of birth (dd/mm/yyyy)*

Age at Time of Assault

Client Ethnicity 1

Client Ethnicity 2

Primary language

Interpreter Required

Gender*

Sexuality

Religion

Issues

Risks

Disabilities*

Please name any other organisations or workers involved

Further information or issues relevant to this referral
(Has the survivor/victim been investigated for any sexual/violent offences?)

Are you aware if client has previously used our services?

Incident Details (if known)

Crime Ref No

Date of Assault (dd/mm/yyyy)

Date Reported (dd/mm/yyyy)

Reported to police

Police Force

Police Force detail

Police Investigating Officer

Presenting incident*
(CSA means 'Childhood Sexual Abuse')

Alleged Perpetrator Name/Desc

Alleged Perpetrator Age

Alleged Perpetrator Relationship

Acquaintance = friends, colleagues, neighbours, step/foster family , i.e. known to the survivor over a period of time
Stranger 1 = perpetrator makes a sudden attack without prior notice
Stranger 2 = Perpetrator makes contact before the assault eg buys a drink, starts a conversation but is not otherwise known to survivor

Forensic Exam Date (dd/mm/yyyy)

Sexual Health Clinic Attended

Open to Court

Court Start Date (dd/mm/yyyy)

Please tick box to show consent given for referral to support services*