Under 18s Referral Form

RASA Merseyside is committed to safeguarding and expects professionals to have made all necessary safeguarding enquires prior to referral to RASA. Referrals will not be accepted without this information.

RASA Merseyside will contact social care, or other relevant agencies, regarding any referral for children and young people under 18 as necessary.

RASA Merseyside is a specialist service, adhering to Rape Crisis National Standards. 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 offences, convicted of any sexual offences, or for anyone who may pose a risk of sexual harm to others.

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.

RASA Merseyside only accepts referrals made by professionals with the children’s parent/guardian’s knowledge and agreement.

Confidentiality

RASA Merseyside Services are confidential, unless there are concerns about safeguarding, immediate risk of harm to self or others, or issues of legality.
RASA Merseyside may only disclose information to the referrer about the service user’s attendance with informed consent from all parties.
RASA Merseyside will not disclose issues discussed within counselling.
RASA Merseyside adhere to confidentiality, Data Protection, and Safeguarding Policies – Available on request

How to make a referral Please complete and submit the form below with as much information as possible. We must be informed by the referrer of the service user’s involvement with other agencies, for example, Social Services or Mental Health services. Required fields are shown with a *

Upon receipt of this referral, we aim to contact the service user within 7 working days.

Referrer Details

Referring Organisation Category*

Referring Organisation*

Referring Organisation Name*

Essential Details

Person Making Referral*

Referrers Tel No*

Referrers Email Address*

Service Details

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)

Client Contact Details

Client type*

Client First Name*

Client Last Name*

Address Line 1*

Address Line 2

Town*

Postcode*

Permission to Leave Voicemail*

Permission to Send Text*

Permission to Contact via Email*

Permission to send Post*

Parent/Guardian details

Primary Contact Type*

Name*

Address Line 1*

Address Line 2

Town*

County

Postcode*

Address Restrictions*

Phone Type*

Phone Number*

Phone Restrictions*

Email Type

Email address

Email Restrictions

Child/Young persons 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

No. of Dependants

Gender*

Sexuality

Religion

Employment status

Accommodation

Living with

Disabilities*

Safeguarding completed*
Please provide details in the Further Information box below.
Include as much detail as possible, including reason for the referral.

Ongoing investigation?*

Social care involvement and level of intervention, e.g. EHAT or Child in need.*

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)

Sexual Health Clinic Attended

Open to Court

Court Start Date (dd/mm/yyyy)

Please tick box to show consent given from parent/guardian for referral to support services.*

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