Survivor Space Oxfordshire Self Referral Form

This form is to refer yourself to Survivor Space's face-to-face services.

Please complete this form with as much information as possible. If there is a question you feel uncomfortable answering here and would prefer to discuss in person, feel free to leave it blank.

If you need support to complete this form, please contact us on referrals@survivorspace.org.uk.

Your information will be kept safe and treated with care and respect. Information will be shared where there is a legal obligation of safeguarding concern/risk. Your personal information will not be shared with anyone outside of Survivor Space without your explicit consent in line with the principles of the Data Protection Act 1998.

Children and Young People services are confidential and the information provided by survivors is confidential unless anyone under the age of 18 years old is in danger or at risk of significant harm.

Required fields are shown with a *

Person being referred

First Name*

Last Name*

Tel No*

Email Address

Address Line 1

Address Line 2

District*

Postcode*

Permission to Leave Voicemail*

Permission to Send Text*

Permission to Contact via Email*

Permission to send Post*

Date of birth (dd/mm/yyyy)*

GP Name / Practice or Surgery Name

Ethnicity 1*

Ethnicity 2

Ethnicity 3

Primary language*

Interpreter Required

Gender*

Sexuality

Religion

What is your employment/education status?

Disabilities*

Dependants

Any children and any adults who are dependent on your care

Dependant 1

Name

Gender

Date of birth

Dependant 2

Name

Gender

Date of birth

Dependant 3

Name

Gender

Date of birth

Your experience(s) of sexual violence

Which of the following best describes the abuse/assault?
(CSA means 'Childhood Sexual Abuse')

Date of Assault (dd/mm/yyyy)

Reported to police*

Crime Ref No

What is the perpetrators relationship to you?
(e.g. friend, cousin, stranger)

Service information

Please select from the options below.

IF YOU ARE UNSURE WHICH SERVICE IS APPLICABLE PLEASE CLICK ON THE SERVICE CRITERIA/EXPLANATION BELOW:*
(Young people means 18 and under, Older people means 65+)

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

ADULT THERAPEUTIC SERVICES

Our counselling service offer up to 12 specialist 1-1 counselling sessions for women and non-binary individuals recorded female at birth.

You can also access groups whilst you are waiting for support. These groups include arts and craft, yoga sessions, virtual coffee mornings and monthly webinars and those on our website.

We also offer pre-recorded psychoeducation videos and workbooks. The psychoeducation will explore the psychology of trauma and sexual violence and how it can impact your body and mind.

YOUNG PEOPLE COUNSELLING SERVICE

Our young people counselling service offer specialist 1-1 counselling to young people aged 12 - 18 years old.

INDEPENDENT SEXUAL VIOLENCE ADVISOR (ISVA)

Our Community ISVAs offer practical and emotional support for survivors of any gender who are considering reporting an experience of sexual violence, or who have already reported to the police. They can offer support with the reporting process, accompanying to meetings, and advocate on a survivors behalf with the police and other agencies. We can also sometimes provide practical support with other issues related to the sexual violence you have experienced - e.g. housing, employment issues etc.

Please choose one of the following services:

Our Brookes University ISVA service is dedicated to supporting students at Brookes University.
Our Community ISVA service is dedicated to supporting survivors across Oxfordshire.
Our Disability ISVA service is dedicated to supporting survivors with physical, learning or sensory disabilities living in Oxfordshire.
Our Older Adult ISVA service is dedicated to supporting survivors ages 65 years old and above living in Oxfordshire
Our Young People ISVA service is dedicated to supporting young people aged 14 to 18 across Oxfordshire.
Our Oxford University ISVA service is dedicated to supporting students at Oxford University.

GROUPS

The groups are open to women and non-binary individuals recorded female at birth over the age of 18 who has experienced sexual abuse or rape, whether in the past or recently, as a child or as an adult.

You can find out about our current groups on our website.

NOTE: Waiting times will vary from service to service due to the demand and number of people on the waiting list. Individuals may be offered an alternative ISVA service to the one selected. E.g. Individuals with mental health disability may be supported by the Community ISVA.

Please detail which group you would like to join in the additional information box below.

PLEASE NOTE

We can discuss options for specialist support for men.

If you are male, trans male or non-binary recorded male at birth and seeking counselling or other therapeutic support, please see the services listed here: Counselling for Male Survivors

Additional information

Further information or issues relevant to this referral
(If you referred to Groups, please specify which one(s). If you are a student at school, college or university, please provide additional info here e.g. the name of your school, college and course.)
Please state preferred days for us to contact.

Please tick box below to show consent given for referral to Survivor Space services and agreement to Survivor Space’s privacy policy*