Referral Form

Welcome to our online referral form

Please complete the below form with as much information as possible

Our Criteria for support

We support anyone who lives or works in Lincolnshire, who has been affected by any form of sexual violence at any point in their lives and is willing to engage in support/therapy relating to these experiences.

We will only accept referrals for those who are aware that their information is being referred to us. Please tick this box to confirm this. *

We are a survivor 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.

By ticking this box, you and the person being referred agree for checks to be made regarding their risk status. LRC reserve the right to refuse the provision of services.

I confirm that the person being referred does not pose a risk of harm to others. Please tick this box to confirm this. *

Once we have received and processed this form one of our staff team will call the client you have referred to arrange a telephone assessment. They can expect a call from us in less than five working days. If it is not convenient for them when we call we will arrange a suitable time to call them back. When we call them, they will have the opportunity to ask any questions they may have and we will ask them for some more information about why they need to access support with us.

We will only disclose information to the referrer about the client’s attendance with written permission from all parties.

We will not disclose issues discussed without the written consent of the client.

Referring agencies must inform us of any known risks to or from the service user.
We will not disclose issues discussed without the written consent of the service user unless there are safeguarding concerns.
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

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

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

Forensic Exam Date (dd/mm/yyyy) (dd/mm/yyyy)

Sexual Health Clinic Attended

Open to Court

Court Start Date (dd/mm/yyyy) (dd/mm/yyyy)

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