Self Referral Form

Before you begin

We are a victim focused organisation and as such we do not work with perpetrators of sexual, domestic or violent offences.

If you would like further information please contact the team on 01773 746115 to discuss support available.

THANK YOU FOR REFERRING TO SV2.

Please complete the form below with as much information as possible and ensure that the person you are referring is aware and has consented to the referral. The form will be sent via a secure connection (SSL), which is encoded and goes straight into our database, accessed by SV2 staff only.

You can see our privacy notice at https://www.sv2.org.uk/sv2-privacy-policy/

Before submitting a referral please read the service criteria/explanation within the service details section below, this will help you to decide which service or services will most benefit the person you’re referring.

Upon receipt of the referral we aim to make contact with the survivor as soon as possible and this is usually within 5 working days.

Required fields are shown with a *

Support required

Please refer to our website for further definition of services available.

Independant Sexual Violence Advice

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

Independent Sexual Violence Advisor

SV2 provides an ISVA (Independent Sexual Violence Advisor) or CHISVA (Children’s Independent Sexual Violence Advisor) service for anyone who has been the victim of rape, sexual assault or abuse. There is a vast range of support that an ISVA/CHISVA can offer, but their main role is to provide emotional and practical support for anyone who has experienced current or historic rape, sexual abuse or assault.

ISVAs support those who are over 18, ChISVAs work with under 18’s and their families.

If you have reported to the police or would like some further information about the reporting process an ISVA can offer support and advise on the Criminal Justice System. We are independent from the police and other agencies.

You do not have to report to the police to receive support from an ISVA.

Children’s therapy

We offer therapy to children and young people so they can explore their thoughts, feelings and experiences in a way that works best for them.

This can involve talking, but also creative therapy and play.

This is available to children and young people aged 0 upwards for both historic and recent events of sexual abuse.

Adult’s therapy

Counselling and therapy is available to anyone regardless of age, gender or when the assault/abuse took place. You do not have to report an incident to be able to engage in our therapy service.

Counselling and therapy cover a range of talking therapies. Where talking about emotions feels difficult, our therapists will help you to find other ways to express your feelings such as writing, drawing and other creative methods you feel comfortable with.

Therapy might include talking about your life experiences, (past and present), feelings, emotions, relationships, ways of thinking and patterns of behaviour. Our therapists will do their best to help you to look at your current difficulties and help you find healthier ways of coping.

Our therapy waiting list is currently full and we are not able to accept any more referrals at the moment. Please check the resource library on our website for help, you can also contact your GP or call Rape Crisis helpline on 0808 500 22 22 which is open 24 hours. We hope to be able to accept referrals again soon, please keep an eye on our website and social media.

Client Details

Client First Name*

Client Last Name*

Date of birth (dd/mm/yyyy)*

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

GP*

Additional Details

Date of Assault (dd/mm/yyyy) *

Reported to police

Crime Ref No

Client Ethnicity 1

Client Ethnicity 2

Gender*

Sexuality

Religion

Primary language

Nationality

Marital status

Employment status

Disabilities*

Risks

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

Please state your preferred form of communication (Phone/Mail/Email)*

Are there any preferred days/times for us to contact you?

Also, do you have a preferred support method (In person/Remote)

If there is any current risk of abuse, please give details

Have you previously used our services?

Please tick box to confirm you have given consent for referral to support services *