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 subject (the suspect) to an ongoing police investigation. Referrals for clients open to police investigation are considered on a case-by-case basis, to determine whether we are the appropriate service and can provide support.

Please complete the below form with as much information as possible.

Referrals will only be processed once consent has been received.

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 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.

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. We reserve the right to refuse the provision of services.

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

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Client Contact Details

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Additional Details

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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.

Client under 18 years old
Educational setting
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(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)
Incident Details (if known)

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(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)

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


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