Organisation Referral Form

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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 Tel No

Service Details

Please select one of the options below.

IF YOU ARE UNSURE WHICH SERVICE IS APPLICABLE PLEASE CLICK ON THE SERVICE CRITERIA/EXPLANATION BELOW:*

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

Counselling

We offer counselling to survivors of rape and sexual abuse, aged 11+ provided by qualified counsellors and counselling students in their final year of placement.

Counselling takes place on a weekly/fortnightly basis depending on the client’s availability, and may be short or long term depending on the individual’s needs.

Supporters and carers of survivors may also access this service if they have been affected by the survivor’s experience of sexual violence or abuse.

Please be aware if counselling has been requested we do have a waiting list.

ISVA (Independent Sexual Violence Advisor)

Our ISVA team are independent specialist workers who can provide practical and emotional support to individuals, aged 5years and over, who have experienced rape or sexual abuse at any time in their life and may be considering reporting to the police. The worker will support you regardless of whether you are reporting the matter to the police or not.

The ISVA team consists of:

Independent Sexual Violence Advisors (ISVAs), who provide support to individuals aged 18+.
Children & Young People’s Independent Sexual Violence Advisors (ChISVAs) who provide support to individuals aged 5-17, a ChISVA may also work with individuals aged 18-25 where they have additional needs.

Family Independent Sexual Violence Advisors (FISVAs) who provide support to the supporters of survivors, most commonly parents, partners and family members. The FISVA role enables the youngest survivors of sexual violence, those aged 5 and under, to receive support through the FISVA engagement with their parent or carer.

CSE (Non CJS)

Our Branch Project Workers (CSE) are independent specialist workers that can provide practical and emotional support outside of the criminal justice process. The support is tailored to the individual needs of children and young people who are at risk of or have been a victim of CSE. We can offer one to one support which focuses on: protective behaviours, coping strategies, consent and developing healthy and trusted relationships. We also offer training and education to parents and professionals.

Client Contact Details

Address Line 1

Address Line 2

Town*

District*

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

Nationality

Immigration status

Primary language

Interpreter Required

Marital status

No. of Dependants

Gender*

Sexuality

Religion

Employment status

Accommodation

Living with

Issues

Risks

Disabilities*

Please name any other organisations or workers involved

Further information or issues relevant to this referral
(Has the survivor/victim been investigated for any sexual/violent offences?)

Are you aware if client has previously used our services?

Assault Details (if known)

Crime Ref No

Date of Assault (dd/mm/yyyy)

Date Reported (dd/mm/yyyy)

Reported to police

Police Force

Police Force detail

Police Investigating Officer

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

Alleged Perpetrator Name/Desc

Alleged Perpetrator Age

Alleged Perpetrator Relationship

Acquaintance = friends, colleagues, neighbours, step/foster family , i.e. known to the survivor over a period of time
Stranger 1 = perpetrator makes a sudden attack without prior notice
Stranger 2 = Perpetrator makes contact before the assault eg buys a drink, starts a conversation but is not otherwise known to survivor

Forensic Exam Date (dd/mm/yyyy)

Sexual Health Clinic Attended

Open to Court

Court Start Date (dd/mm/yyyy)

Does the survivor have a preference to a male or female worker?*

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