Professional Referral Form

Before you begin

Ben’s Place is unable to offer support to those who are under investigation or have convictions for sexual offences.

This form is currently being developed and as a result we would ask you to contact us if you haven't heard from us after a couple of days in case there has been an issue with the form posting.

Please complete the referral form with as much information as possible. It is important that the referral form is completed in full. Incomplete forms may not be accepted, and the referrer may need to complete again online. This may result in significant delays to an assessment being offered.

We may only disclose information to the referrer about the client’s attendance and any issues discussed with the written consent of the client.

We will only accept referrals for those who have agreed to connect and who are aware that the referral has been made.

We will accept referrals for male survivors of sexual violence.
We must be informed by the referrer of the client’s involvement with other agencies e.g. Social Services, Probation Services or Mental Health Services. This is particularly important if the client is involved in care proceedings for example.
Referring agencies must inform us of any known risks to or from the client.

Required fields are shown with a *

* Please remember to click submit.

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 Email Address*

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*