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, 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 01782 433204 or email: firstname.lastname@example.org.
We are a survivor focused organisation and as such we do not accept referrals for anyone who is subject (the suspect) to an ongoing police investigation for sexual, domestic or violent offences, or for anyone who may pose a risk of harm to others.
Please confirm that the person being referred does not pose a risk of harm to others, and is not subject (a suspect) in an ongoing Police investigation for violent or sexual offences (tick box)*
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.
Savana provides support to anyone impacted by sexual violence who lives in Stoke on Trent and expresses a desire to engage in support/therapy relating to these experiences.We will only accept referrals for those who are aware that their information is being referred to us. Please tick this box to confirm this. (tick box)*
We have a counselling service which provides one to one support to work through the impacts of sexual abuse. We also have an ISVA service for anyone who requires practical support e.g. support through an ongoing police investigation regarding a sexual offence.
Once we have received and processed this form one of our staff team will call the client you have referred to arrange an initial telephone appointment. They can expect a call from us in within five working days. If it is not convenient for them when we call we will arrange a suitable time to call them back. When we call them, they will have the opportunity to ask any questions they may have and we will ask them for some more information about why they need to access support with us.
We will only disclose information to the referrer about the client’s attendance with written permission from all parties.
We will not disclose issues discussed without the written consent of the client.
- 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.
Required fields are shown with a *
Service Details/ Explanation of services (Click here to show/hide details)
Client Contact Details
Please only enter the first part of your Postcode. We only accept referrals in Stoke on Trent (ST1,2,3,4,6),
Incident Details (if known)
Please enter a Police Crime Ref No
Please enter a Date of Assault
Please enter a Police Date Reported
Please enter a Police Force
Please enter a Police Investigating Officer
(CSA means 'Childhood Sexual Abuse')
Please enter the Alleged Perpetrator Name
Please enter the Alleged Perpetrator Relationship