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.

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 Contact Details

Client Tel No

Client Email Address

Address Line 1*

Address Line 2

Town*

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

Gender*

Please see our Equality and Diversity policy, available on our website, for more information

Sexuality

Religion

Disabilities*

Reasons for referral – why does the client want to come to RASASC North Wales for support? Is there any other relevant information, or risks, that it would be helpful for us to know about? (including any information about past investigations for any sexual/violent offences)

Are you aware if client has previously used our services?

Assault Details (if known)

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

Reported to police*

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