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

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Essential Details

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Client Contact Details

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Additional Details

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Assault Details (if known)

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(CSA means 'Childhood Sexual Abuse')
 (dd/mm/yyyy)
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Please tick box to show consent given for referral to support services*