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 or a safeguarding concern, please contact your local authority safeguarding service.

IMPORTANT PLEASE READ: Before submitting a referral, please pay attention to the information within the service details section, this will help you to refer your client to the correct service/s. If you have difficulties completing this form, please contact our main referral hub on 01905 677444 or email: enquiries@purpleleaf.org.uk.

Please note that referrals for clients open to police investigation would be considered on a case-by-case basis, to determine whether we are the appropriate service and can provide support.

Please complete the below form with as much information as possible. We may only disclose information to the referrer about the service user’s attendance with written permission from all parties.

Referrals will only be progressed once consent has been gained

Referring agencies must inform us of any known risks to or from the service user.
By ticking this box (tick box)* you and the person being referred agree for checks to be made regarding their risk status. We reserve the right to refuse the provision of services.

We will not disclose issues discussed without the written consent of the service user unless there are safeguarding concerns.
We must be informed by the referrer of the service user’s involvement with other agencies e.g. Social Services, Probation Services or Mental Health Services.

This referral cannot be submitted unless the above information is confirmed. By ticking this box, you and the person being referred agree for checks to be made regarding their risk status. We reserve the right to refuse the provision of services.

We will only accept referrals for those who are aware that the referral is being made.

Referring agencies must inform us of any known risks to or from the service user.
We will not disclose issues discussed without the written consent of the service user unless there are safeguarding concerns.
We must be informed by the referrer of the service user’s involvement with other agencies e.g. Social Services, Probation Services or Mental Health Services.

If the survivor is under 18, have they been referred to the West Midlands Children and Young People’s Service (CYPS)?

This is a unique partnership between the NHS, private sector and voluntary agencies, working together to bring specialist skills and experience to deliver best care and preserve best evidence.

General referral criteria - ALL four bullet points must apply:

child/young person under the age of 18 years OR aged 18-20 with significant learning difficulties AND in full-time education
resident, looked-after child or victim of offence within catchment (area served by West Mercia, Staffordshire, Warwickshire or West Midlands police force areas)
referred to children’s social care/Multi Agency Safeguarding Hub (MASH)
child/young person must be aware of referral and consent.

To make a referral to the CYPS, please call 0808 196 2340

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 First Name*

Client Last Name*

Client Tel No

Client Email Address

Service Details

Please select one of the options below.

IF YOU ARE UNSURE WHICH SERVICE IS APPLICABLE PLEASE CLICK ON THE SERVICE CRITERIA/EXPLANATION BELOW:*

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 (if applicable)

Client Ethnicity 1

Client Ethnicity 2

Nationality

Immigration status

Primary language

Interpreter Required

Marital status

No. of Dependants

Gender*

Sexuality

Religion

Employment status

Accommodation

Living with

Additional information

Risks

Disabilities*

Please name any other organisations or workers involved

Further information or issues relevant to this referral
(Core reason(s) for making this referral,has the person being referred been investigated for any sexual/violent offences?)

Are you aware if client has previously used our services?

Incident Details (if known and applicable)

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' No incident means that they have not been a survivor of 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)

Does the young person have a preference to a male or female worker?*

Contact details

Parent / Carers contact Details*

Name*

Email address and contact number*

Contact Type 2*

Contact Name 2*

Address details and contact number*

Contact Type 3

Contact Name 3

Address details and contact number

Please tick box to show consent given for referral to Purple Leaf services*