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.


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.


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, domestic or violent offences, or for anyone who may pose a risk of harm to others.

Please confirm that the person being referred does not pose a risk of harm to others, and is not known to Police regarding violent or sexual offences (tick box)*  

This referral cannot be submitted unless the above information is confirmed. By ticking this box, you and the person being referred agree for checks to be made regarding their risk status. WMRSASC reserve the right to refuse the provision of services.

Please complete the below form with as much information as possible. We may only disclose information to the referrer about the service user’s attendance with written permission from all parties.

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

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

If the survivor is under 18, have they been referred to Paediatric Sexual Assault Service (PSAS)?

PSAS 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, Warwickshire or West Midlands Police)
  • 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 PSAS, please call 0800 953 4131


Required fields are shown with a *

Referrer Details

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Essential Details

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Service Details

Please select one of the options below.
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Service criteria /explanation of services (Click here to show/hide details)
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')

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