Referral Form: Organisation

Before you begin

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 ARCH staff only.


IMPORTANT PLEASE READ: 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 be of most benefit.


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

Please note, we will only accept referrals for those who have agreed to attend and who are aware that the referral has been 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 if the person has any involvement with other agencies e.g. Social Services, Probation or Mental Health Services. This is particularly important if the person is involved in any care proceedings.
  • Referring agencies must inform us of any known risks to or from the person referred.

Required fields are shown with a *

Referrer Details

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Organisational Unique Identifier Number
Essential Details

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Service Details

Please select at least one or both of the options below, do not leave both as 'None'.
Service criteria /explanation of services (Click here to show/hide details)
Client Contact Details

If the survivor/victim does not reside in any of the listed districts, please contact Referral Team on 01642 822331 / 01642 822335
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Additional Details

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GP Name / Practice or Surgery Name
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Assault Details (if known)

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(CSA means 'Childhood Sexual Abuse')
 (dd/mm/yyyy)
 (dd/mm/yyyy)

Please tick box below to show consent given for referral to support services*