Referral Form: Organisation

Before you begin

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 use the contact details below (if your Client lives within Teesside Area).

SARC Teesside provides a 24/7 Advice Line for Professionals and Survivors of Sexual Assault. You can contact them on 01642 516888 or you can contact Teesside Samaritans on 01642 217777.


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.

Select the drop down box named (Service criteria/explanation of services).


Complete the Form below with as much information as possible. We may only disclose information with permission from all parties.

We will only accept referrals for those who have agreed to attend and who are aware that the referral has been made. The referral team will then make initial contact with the Victim/Survivor/Supporter within 7 working days to complete the process.

  • We will accept referrals for Supporters and Survivors of Sexual Violence.
  • We must be informed by the Referrer of 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*