Referral Form

For professionals with clients who would like support from RASASC North Wales

Before you begin

RASASC North Wales provides a counselling service for anyone from the age of 3 and over who has experienced any form of sexual violence or abuse at any time in their lives. We also provide counselling support for friends, family and professionals who have been affected themselves through supporting survivors. Our counselling service is delivered various locations across the six counties of North Wales - Gwynedd, Anglesey, Conwy, Denbighshire, Flintshire and Wrexham.

RASASC North Wales is a specialist service, adhering to Rape Crisis England and Wales and Survivors Trust National Standards, and is an organisational member of BACP.

How to make a referral.

Please complete and submit the form below, with as much information as possible. RASASC North Wales accepts referrals made by professionals with the applicant’s knowledge and agreement. You must inform RASASC North Wales of any known risks to or from the client.

Confidentiality

  • RASASC North Wales services are confidential, unless there are concerns about safeguarding, immediate risk of harm to self or others, or issues of legality
  • RASASC North Wales adhere to Confidentiality, Data Protection and Safeguarding Policies – available on request.

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Referrer Details

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Essential Details

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Client Contact Details

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Additional Details

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Please see our Equality and Diversity policy, available on our website, for more information
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Please tick box to confirm the client has consent given for referral to support services*

We are an organisation for survivors of sexual violence and abuse. Please confirm that, to your knowledge, the person being referred is not being investigated for criminal offences, and does not pose a risk of harm to others (tick box)*    
If yes, please contact the office on 01248 670 628