Referral Form

For professionals with clients who would like support from Chester Sexual Abuse Support Service (CSASS)

Before you begin

CSASS provides a counselling service for anyone over the age of 18 who has experienced any form of sexual violence or abuse at any time in their lives. We also provide counselling support for friends, family and professionals who have been affected themselves through supporting survivors. Counselling is delivered at our office, in Chester city centre.

Counselling can be hard work, and survivors need to be able to commit to attend appointments reliably, in order for it to be effective and helpful. Please consider our LiveChat or supportline, or monthly drop-in group, for survivors who might not be ready for counselling yet.

CSASS is a specialist service, adhering to Rape Crisis National Standards, and is an organisational member of BACP.

How to make a referral.

Please complete and submit the form below, with as much information as possible. CSASS accepts referrals made by professionals with the applicant’s knowledge and agreement. You must inform CSASS of any known risks to or from the client.

Confidentiality

CSASS services are confidential, unless there are concerns about safeguarding, immediate risk of harm to self or others, or issues of legality
CSASS may only disclose information to the referrer about the service user’s attendance with informed consent from all parties.
CSASS will not generally disclose issues discussed within counselling.
CSASS adhere to Confidentiality, Data Protection and Safeguarding Policies – available on request.

Required fields are shown with a *

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 Contact Details

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

Additional Details

Date of birth (dd/mm/yyyy)*

Age at Time of Assault

Client Ethnicity 1

Client Ethnicity 2

Gender*

Please see our Equality and Diversity policy, available on our website, for more information

Sexuality

Religion

Disabilities*

Reasons for referral – why does the client want to come to CSASS for support? Is there any other relevant information, or risks, that it would be helpful for us to know about? (including any information about past investigations for any sexual/violent offences)

Are you aware if client has previously used our services?

Please tick box to confirm the client has consent given for referral to support services*

We are an organisation for survivors of sexual violence and abuse, and as such we do not accept referrals for anyone who is being investigated by the police for sexual, domestic or violent offences, or for anyone who may pose a risk of harm to others. Please confirm that, to your knowledge, the person being referred is not being investigated for these offences, and does not pose a risk of harm to others (tick box)*