Professional Referral Form

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)*  

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. Leicester Rape crisis reserve the right to refuse the provision of services.

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, it does not matter if the assault happened recently or in the past.
  • We will only accept referrals from Leicestershire.
  • 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.
  • 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 *

If you are having problems completing this form or require any assistance, please contact the volunteer co-ordinator at volunteering@jasminehouse.org.uk.


REFERRER DETAILS

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ESSENTIAL DETAILS

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CLIENT CONTACT DETAILS

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ADDITIONAL DETAILS

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ASSAULT DETAILS (if known)

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