Organisation Referral Form


Before you begin completing this online form please note we are happy to answer any questions you may have however, we do not provide a crisis service.
In case of an Emergency please call 999.


IMPORTANT PLEASE READ: Before submitting a referral please pay attention to the Information within the Service Details section, this will help you to refer your client to the correct service/s. If you are unsure about which service to refer to, then please feel free to contact the office on 0151 558 1801.


We are a survivor focused organisation and as such we are unable to accept referrals for anyone who is currently under investigation for committing a sexual offence or anyone who has a conviction for a sexual offence.

Please confirm that the person being referred is not known to Police regarding 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. RASA Merseyside reserve the right to refuse the provision of services.

RASA Merseyside provides support to anyone impacted by sexual violence. We have a counselling service which provides one to one support to work through the impacts of sexual abuse. We also have an ISVA service for anyone who has an ongoing police investigation regarding a sexual offence.

Service Criteria/ Explanation of services

Counselling

We offer counselling to survivors of rape and sexual abuse provided by qualified counsellors and counselling students in their final year of placement. Counselling takes place on a weekly basis depending on the client’s availability. Supporters and carers of survivors may also access this service if they have been affected by the survivors’ experience of sexual violence or abuse.

Please be aware if counselling has been requested, we do have a waiting list.


ISVA (Independent Sexual Violence Advisor)

Our ISVA team are independent specialist workers who can provide practical and emotional support to individuals who have experienced rape or sexual abuse at any time in their life. The worker will support you regardless of whether you are reporting the matter to the police or not.

The ISVA team consists of:

  • Independent Sexual Violence Advisors (ISVAs), who provide support to individuals aged 18+.
  • Children & Young People’s Independent Sexual Advisors (ChISVAs) who provide support to under 18’s. A ChISVA may also work with individuals aged 18-25 where they have additional needs.

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 only accept referrals for those who have consented to the referral and who are aware that the referral has been made.

  • 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.

Required fields are shown with a *

Referrer Details

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Essential Details

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If client doesn't have an email address type 'None'
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Client Contact Details

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Additional Details

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Please choose multiple options if necessary and select 'None' if you are not aware of any issues
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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*


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