Agency Referral Form for the London Survivors Gateway

The Gateway is currently only able to accept a limited number of referrals per week.
Once we have received this number of referrals we will then close to new referrals until the following week.

To check if we are open, click here.

  • When open, you must have obtained the client’s consent to refer them to our service.
  • When closed, please do not make referrals.

Please note that we are not a crisis service and we cannot support clients who have immediate crisis needs in terms of their safety both internally and externally. We are currently experiencing peak demand and it can take us a number of weeks to get in touch with clients. As such, we ask that any immediate pressing needs are met outside of the Gateway before a referral is made to ensure the safety and wellbeing of the client. This includes all the appropriate safeguarding referrals.

Before you refer

  • Please check we are open for referrals
  • If you are making a referral for someone who has been assaulted within the last 7 days and it is outside of office hours please contact the Havens directly on 020 3299 6900.
  • If the person you are referring has recently experienced or is currently experiencing domestic abuse please confirm that you have also referred into domestic abuse services and completed all necessary safeguarding referrals (including MARAC referrals if appropriate). We will be unable to process your referral without this.
  • Please ensure that the person you are referring would like support for their experience of being a victim/survivor of sexual violence specifically.
  • You must obtain consent from the person you are referring.

Information submitted on this referral form will be treated as confidential and stored securely on the Women and Girls Network data management system. Information is only shared with third parties with the explicit consent of the person being referred or if there is a risk of significant harm or safeguarding concerns.

Please tick this box to confirm that that you accept the above and that the individual below has consented for this referral.*
Referrer details
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Client details
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Client contact details
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Please state if the above Tel No is NOT the client’s number and explain this in the referral.
Monitoring details
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Does the referee identify as trans or having a trans history?
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To expand, pull the bottom right of input box.

Please provide a brief explanation for the reason for this referral and include information on safeguarding or risk issues*
Please give details of clients Mental health.
Please give details of clients safety and what measures have been taken.
To expand, pull the bottom right of input box.
PLEASE NOTE IF THIS CLIENT IS EXPERIENCING DOMESTIC VIOLENCE OR IS IN A MENTAL HEALTH CRISIS WE MAY NOT BE THE FIRST POINT OF CALL. PLEASE REFER TO THE SERVICE MAP OR CRISIS SUPPORT IF THE CLIENT IS PRESENTING WITH EITHER ISSUE.
Assault details (if known)
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(CSA means 'Childhood Sexual Abuse')
Consent is required