OSARCC Referral Form

This form is to refer yourself or someone else to OSARCC's face-to-face services.

Please complete this form with as much information as possible. If there is a question you feel uncomfortable answering here and would prefer to discuss in person, feel free to leave it blank.

If you need support to complete this form, please contact us on 01865 725311.

Your information will be kept safe and treated with care and respect. Information will be shared where there is a legal obligation of safeguarding concern/risk. Your personal information will not be shared with anyone outside of OSARCC without your explicit consent in line with the principles of the Data Protection Act 1998.

We would recommend that survivors who require support refer themselves directly. However, if they are not able to do this, professionals and supporters can also make a referral via this form.

You must have the consent of the survivor to make a referral on their behalf.

The SEE Project services are confidential and the information provided by survivors is confidential unless:
a young woman and girl or anyone under the age of 18 years old is in danger or at risk of significant harm.

Required fields are shown with a *

Referrer

Referrer Type*

Referrer Type 2*

Referring Organisation Name*

Person Making Referral*

Referrers Tel No*

Referrers Email Address*

Referral Date (dd/mm/yyyy)*

Person being referred

First Name*

Last Name*

Tel No*

Email Address

Address Line 1

Address Line 2

District*

Postcode

Permission to Leave Voicemail

Permission to Send Text

Permission to Contact via Email

Permission to send Post

Date of birth (dd/mm/yyyy)*

GP Name / Practice or Surgery Name

Ethnicity 1

Ethnicity 2

Ethnicity 3

Primary language

Interpreter Required

Gender*

Sexuality

Religion

What is your employment/education status?

Disabilities*

Dependants

Any children and any adults who are dependent on your care

Dependant 1

Name

Gender

Date of birth

Dependant 2

Name

Gender

Date of birth

Dependant 3

Name

Gender

Date of birth

Your experience(s) of sexual violence

Which of the following best describes the abuse/assault?
(CSA means 'Childhood Sexual Abuse')

Date of Assault (dd/mm/yyyy)

Reported to police

Crime Ref No

What is your relationship to the perpetrator?
(e.g. friend, cousin, stranger)

Service information

Please select one of the options below.

IF YOU ARE UNSURE WHICH SERVICE IS APPLICABLE PLEASE CLICK ON THE SERVICE CRITERIA/EXPLANATION BELOW:

Service criteria /explanation of services (Click here to show/hide details)

COMMUNITY INDEPENDENT SEXUAL VIOLENCE ADVISOR (ISVA)

Our Community ISVAs offer practical and emotional support for women in Oxfordshire who are considering reporting an experience of sexual violence, or who have already reported to the police. They can offer support with the reporting process, accompany women to meetings, and advocate on their behalf with the police and other agencies. We can also sometimes provide practical support with other issues related to the sexual violence you have experienced - e.g. housing, employment issues etc.

There is currently a FOUR MONTH waiting time for our Community ISVA Service. The Victims First Specialist Service may be able to offer support more quickly. You can contact them on 0300 1234 148.

OXFORD UNIVERSITY INDEPENDENT SEXUAL VIOLENCE ADVISOR (ISVA)

Our specialist university ISVA offers specialist advice, support and advocacy to students at the University of Oxford to help you come to decisions about what is right for you. The ISVA is employed by OSARCC and is independent from the university. She can provide you with impartial information about your options following an experience of sexual violence, including reporting to the police or the university. If you decide to report, or have already reported, she can support you throughout the criminal justice process. She can accompany you to meetings and advocate on your behalf with the police and other agencies.

THERAPEUTIC SERVICES

Our therapeutic services include both support groups and one-to-one counselling. There is currently a significant waiting list for both services of around a year, but we are working on ways to reduce this.

We also run fortnightly drop-in groups which are open to any woman who has been assessed for our adult services. Our drop-in group aims to help survivors connect with each other and with themselves. We do that through creative activities, hands-off body work such as Reiki and yoga, and by learning how to manage the physical and emotional effects of trauma and sexual violence. We meet twice a month, alternating between days and evenings.

SEE PROJECT

SEE is a service supporting girls and young women survivors of sexual violence aged 14 - 18 years old. We offer specialist one to one support including both one-to-one counselling and empowerment work (practical and emotional support to build up self-esteem, assertiveness, emotional resilience and improve well-being).

Additional information

Further information or issues relevant to this referral
(If you are a student at school, college or university, please provide additional info here e.g. the name of your school, college and course.)

Please tick box below to show consent given for referral to OSARCC services*