Professional Referral

Before you begin

We are a victim 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 known to Police regarding violent or sexual offences (tick box)*  
If unable to confirm please contact our office on 0330 363 0063 to discuss support available.

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. RASASC (Cheshire and Merseyside) reserve the right to refuse the provision of services. Our telephone number is 0330 363 0063.

If the incident has happened very recently the individuals health is a priority to us so we would advise the person sees a medical professional if they haven’t done so already.
A Sexual Assault Referral Centre can discuss their sexual health needs and may offer a forensic medical examination– evidence can then be stored if the individual has not yet decided whether or not to report to the police. If they live or have been raped/assaulted in Merseyside the local SARC is SAFEPlace Merseyside, please contact them on 0151 295 3550. If they live or have been raped/assaulted in Cheshire please ring 0161 276 6515 to access the service of St Mary's SARC.

Parental or caregiver consent is required for referrals under 16 years of age please provide both name and telephone number in client contact detail section.

Please complete the below form with as much information as possible. We may only disclose information to the referrer about the service user’s attendance with written permission from all parties.

We will not disclose issues discussed without the consent of the service user.

Please confirm that the individual has consented to this referral has agreed to engage with RASASC services. Referrals for under 16 years require parent/caregiver consent.

  • Referring agencies must inform us of any known risks to or from the service user.
  • We will not disclose issues discussed without the consent of the service user unless there are safeguarding concerns.
  • We will accept referrals for victims and survivors of sexual violence.
  • 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. This is particularly important if the service user is involved in care proceedings.

Required fields are shown with a *

Referrer Details

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Essential Details

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Client Contact Details

If client under 18 please provide caregivers contact details
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Additional Details

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( eg Mental health, Social Care or Drug and Alcohol services )

Has the survivor/victim been investigated for any sexual/violent offences?
Please provide further details including any formal mental health diagnosis.
Assault Details (if known)

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(CSA means 'Childhood Sexual Abuse')