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 or for a safeguarding concern, please contact your local authority safeguarding service.

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 01905 611655 or email: referrals@wmrsasc.org.uk.

WMRSASC is primarily a survivor focused organisation, as such, we reserve the right not to accept referrals for anyone who is under investigation in an ongoing police investigation for sexual, domestic or violent offences, or for anyone who may pose a risk of harm to others.

Please contact us on 01905 611655 if you would like to discuss a potential referral.

We will not disclose issues discussed without the written consent of the service user, unless there are safeguarding concerns and/or a court order.
We may only disclose information to the referrer about the service user’s attendance, with written permission from all parties.
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.
Referrals will only be processed if the client is aware and has consented to the referral.

By ticking this box * , you confirm that you are aware of the above information, that you have notified us of any known risks and that the client consents to the referral.

Please complete the below form with as much information as possible in relation to known risks to other clients and/or staff or of any known risks to the client.

We will only accept referrals for those who are aware that the referral is being made.

If the survivor is under 18, have they been referred to the West Midlands Children and Young People’s Service (WMYCPS)?

This is a unique partnership between the NHS, private sector and voluntary agencies, working together to bring specialist skills and experience to deliver best care and preserve best evidence.

General referral criteria - ALL four bullet points must apply:

child/young person under the age of 18 years OR aged 18-20 with significant learning difficulties AND in full-time education
resident, looked-after child or victim of offence within catchment (area served by West Mercia, Staffordshire, Warwickshire or West Midlands police force areas)
referred to children’s social care/Multi Agency Safeguarding Hub (MASH)
child/young person must be aware of referral and consent.

To make a referral to the WMCYPS, please call 0808 196 2340

Required fields are shown with a *

Referrer Details

Referring Organisation Category*

Referring Organisation*

Referring Organisation Name

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)*

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

Additional Information (Please note, more than one Additional information can be added)

Risks (Please note, more than one Risk can be added)

Disabilities (Please note, more than one Disability can be added)*

Please name any other organisations or workers involved

Further information or issues relevant to this referral
Please include a brief description of the incident and current status of any criminal justice process, if known. Please include relevant details and reasons for the referral, this will reduce the need for a client to repeat the information. This reduces the possibility of re-traumatisation and ensures we can tailor support to meet individual needs.

Are you aware if client has previously used our services?

Client under 18 years old

Parent or Carer

Name

Email address and contact number

Educational setting

Educational setting type

Setting and Contact Name

Email address and contact number

Has the client exhibited any sexualised behaviours*

(Children and young people who have exhibited inappropriate/problematic sexualised behaviours towards others or themselves)

(Please note that we do not accept referrals for clients that are open to a Police investigation)

Service Details

Please select one of the options below.*

PLEASE SELECT ONE OF THE FOLLOWING SERVICES. IF YOU ARE UNSURE WHICH SERVICE IS APPLICABLE PLEASE CLICK ON THE SERVICE CRITERIA/EXPLANATION BELOW OR REFER TO OUR SERVICES INFORMATION ON OUR WEBSITE: www.wmrsasc.org.uk/our-services

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

Counselling

We offer counselling to survivors of rape and sexual abuse, aged 5+ provided by qualified counsellors and counselling students in their final year of placement.

Counselling takes place on a weekly/fortnightly basis depending on the client’s availability, and may be short or long term depending on the individual’s needs.

Supporters and carers of survivors may also access this service if they have been affected by the survivor’s experience of sexual violence or abuse.

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

ISVA (Independent Sexual Violence Advocate)

Our ISVA team are independent specialist workers who can provide practical and emotional support to individuals, aged 5 years and over, who have experienced rape or sexual abuse at any time in their life and may be considering reporting to the police. 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 Advocates (ISVAs), who provide support to individuals aged 18+.
Children & Young People’s Independent Sexual Violence Advocates (ChISVAs) who provide support to individuals aged 5-17, a ChISVA may also work with individuals aged 18-25 where they have additional needs.
Family Independent Sexual Violence Advocates (FISVAs) who provide support to the supporters of survivors, most commonly parents, partners and family members. The FISVA role enables the youngest survivors of sexual violence, those aged 5 and under, to receive support through the FISVA engagement with their parent or carer.

Early Intervention and Prevention Services

Assessment and time-limited intervention pathways for children and young people aged 5 to 17 years old.

BRANCH – non-criminal justice advocacy, psychosocial education, and practical support for any young person at risk of/who has been impacted by Child Sexual Exploitation (CSE). Support is extended to young people up to the age of 24 who have an additional need.

Purple Leaf Psychosocial Education – education and information designed to increase young people’s awareness of sexual abuse and exploitation, know how to identify uncomfortable feelings and where to go for help and support.

Children exhibiting sexualised behaviours - advice, risk and needs assessments (Including specialist AIM 3 assessments) and interventions for children and young people who have exhibited sexualised behaviours.

If there is a current police investigation, please select the ChISVA service.

Branch PLUS (Adult Sexual Exploitation) - For anyone living in Herefordshire/Worcestershire.

Branch Plus is a project that recognises sexual exploitation may not end or start just because someone is over 18 years of age. Branch Plus provides support to adults who are impacted by sexual exploitation. This could be in sex work, prostitution, trafficking or when sex is used to survive. There does not need to be a formal disclosure or police involvement to access support from the Branch Plus service.

Pathfinder

Pathfinder Project is a partnership between the NHS and WMRSASC and has a range of services for adults with mental health needs and trauma related to sexual abuse. We have a range of support groups on offer including peer support groups and psychoeducation groups. We are also able to offer one to one support for survivors to access this service and help to stabilise survivors and support them to access mental health services. One-to-one support can also include advocacy and therapeutic support for people who are not in the criminal justice system.

Incident Details (if known)

Crime Ref No

Date of Assault (dd/mm/yyyy)

Age at Time of Assault

Date Reported (dd/mm/yyyy)

Reported to police

Police Force

Police Force detail

Police Investigating Officer

Presenting incident*

(CSA means 'Childhood Sexual Abuse')
(Non-recent relates to survivors who are now 18+)
(No incident means that they have not been a survivor of sexual abuse)

Alleged Perpetrator Name/Desc

Alleged Perpetrator Age

Alleged Perpetrator Relationship

Acquaintance = friends, colleagues, neighbour, step/foster family, i.e. known to the survivor over a period of time
Stranger 1 = perpetrator makes a sudden attack without prior notice
Stranger 2 = Perpetrator makes contact before the assault e.g. buys a drink, starts a conversation but is not otherwise known to survivor

Forensic Exam Date (dd/mm/yyyy)

Sexual Health Clinic Attended

Open to Court

Court Start Date (dd/mm/yyyy)

Does the survivor have a preference for a male or female worker ?*

Please tick box to show consent given for referral to support services*

By submitting this form you understand that the clients data is processed in accordance with our privacy notice