Referral Form

Before you begin

This form is currently being developed and as a result we would ask you to contact us if you haven't heard from us after a couple of days in case there has been an issue with the form posting.

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 written consent of the service user.

We will only accept referrals for those who have agreed to attend and who are aware that the referral has been made.

  • We will accept referrals for 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’s is involved in care proceedings.
  • Referring agencies must inform us of any known risks to or from the service user.
  • 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 or violent offences, or for anyone who may pose a risk of harm to others.

Required fields are shown with a *

Referrer Details

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Essential Details

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Client Contact Details
If the survivor/victim does not reside in any of the listed districts, please contact us on 0300 0037777

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Additional Details

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Assault Details (if known)

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(CSA means 'Childhood Sexual Abuse')
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Please tick box below to show consent given for referral to support services*