ORGANISATION REFERRAL FORM

THANK YOU FOR REFERRING TO SUFFOLK RAPE CRISIS (SRC)

Please complete the form below with as much information as possible and ensure that the person you are referring is aware and has consented to the referral. The form will be sent via a secure connection (SSL), which is encoded and goes straight into our database, accessed by SRC staff only.

INFORMATION BEFORE YOU BEGIN...

Before submitting a referral please read the service criteria/explanation within the service details section below, this will help you to decide which service or services will be of most benefit to whom you are referring.

Upon receipt of the referral we aim to make contact with the survivor as soon as possible and this is usually within 5 working days.

Please note, we will only accept referrals for those who have agreed to engage with SRC and who are aware that the referral has been made.

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

Required fields are shown with a *

REFERRER DETAILS

Referring Organisation Category*

Referring Organisation*

Referring Organisation Name

Organisational Unique Identifier Number

ESSENTIAL DETAILS

Person Making Referral*

Referrers Tel No*

Referrers Email Address**

Client First Name*

Client Last Name*

Client Tel No

SERVICE DETAILS

Please select at least one or both of the options below, do not leave both as 'None'.

Outreach

Counselling

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

Counselling@SRC

Our counselling service offers women and girls up to 25 sessions of free one-to-one counselling on a weekly basis. We offer the service in Ipswich, Bury St Edmunds, Lowestoft, Leiston, and Brandon, or online video counselling. The specialist counselling service is open to anyone who identifies as a woman or girl aged 14 and over who have been affected in any way by sexual violence. This includes childhood sexual abuse, rape, sexual assault, coercive sexual violence within relationships, FGM or so-called ‘revenge porn’ (Image-based abuse). Whatever the sexual violence you have experienced, we are here to offer support. Whether you are a survivor of recent or historic sexual violence you can access our service and find a safe, supportive, non-judgmental environment.

The counselling team are all women and provide a space in which you can feel heard, validated and believed. The service provides a chance to explore what you have survived, the impact this may have had or is having on your day to day life, and help you find ways to move forward and let go of difficult feelings or coping behaviours that are no longer useful to you.

Outreach@SRC

Outreach@SRC is open to anyone who identifies as a woman or girl aged 14 and over who have been affected in any way by sexual violence and over who are survivors of any form of sexual violence across Suffolk.

Outreach@SRC is a support service. An outreach worker can work alongside you on a range of practical issues that you feel you want to address to improve your emotional and physical wellbeing.
You will be at the centre of the work, making choices about what is right for you.
The emotional and practical support offered will be tailored to the needs you have identified with your Outreach Worker in your first meeting together.
Outreach@SRC can offer an empowering space to work creatively and practically.

What can Outreach@SRC offer?

To improve confidence & self-esteem.
Reduce stress in various parts of your life and be able to feel in control of your choices.
Support if you are feeling isolated.
Support with social anxiety.
Practical support to connect with voluntary/ statutory services.
Access counselling; support groups; alternative therapies.
Support with Benefits; debt; housing issues; money problems; budgeting.
Exploring health; fitness; food plans; shopping; getting out & about.
Getting back into education; courses.
Support to attend appointments.
Support with Criminal Justice System.
Anything to make day to day life more manageable when you are not feeling it is

Your Outreach worker will work alongside you to achieve your goal/s, small or large, led by you and for you. Anything that you need to allow you to feel more in control and lessen your load….

CLIENT CONTACT DETAILS

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

Alternative Safe Contact Details

ADDITIONAL DETAILS

Date of birth (dd/mm/yyyy)**

Age at Time of Assault

GP Name / Practice or Surgery Name

Client Ethnicity 1

Client Ethnicity 2

Nationality

Immigration status

Primary language

Interpreter Required

Marital status

No. of Dependants

Sexuality

Religion

Employment status

Accommodation

Living with

Additional relevant information

Risks

Disabilities*

Please name any other organisations or workers involved

Further information relevant to this referral

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'. If specific incident not known please select 'Sexual violence')

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 below to show consent given for referral to support services*