Agency Referral Form for the London Survivors Gateway

You can use the form below to refer people that you are working with into the London Survivors Gateway. You must have obtained their consent in order to do this. The Gateway offers survivors of sexual violence aged 13+ independent advice and referral into specialist sexual violence services in London. The Gateway is a partnership between the four London Rape Crisis Centres, Galop, SurvivorsUK and the Havens and is run by the Women and Girls Network.

The Gateway is able to make contact with individuals aged 13+ of any gender who have experienced sexual violence at any point in their lives. If you are unsure if your referral is suitable or have any further questions please contact us on 0808 801 0860 before completing this referral form.

We endeavour to respond to all referrals within 2 working days.

Before you refer

  • 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.
  • Please ensure that the person you are referring would like support for their experience of being a victim/survivor of sexual violence.
  • 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.

We will use your contact details to confirm receipt of the referral and you may also be contacted by MOPAC’s Evidence and Insight Team to invite you to take part in the project evaluation.

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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Essential details

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Client contact details

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Additional 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*
To expand, pull the bottom right of input box.
Assault details (if known)

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(CSA means 'Childhood Sexual Abuse')

Consent is required