Referral Form

THIS FORM HAS BEEN RETIRED!

This form is no longer active. From 10th December 2023, Synergy Essex has moved to a new referral form.

Please click here to use the new referral form.

Before you begin

We are a victim 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. Essex Rape Crisis Partnership reserve the right to refuse the provision of services.

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

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 will accept referrals for victims and survivors of sexual violence.
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 is particularly important if the service user is involved in care proceedings.
We may only disclose information to the referrer about the service user’s attendance with written permission from all parties.

Required fields are shown with a *

Referrer Details

Referring Organisation Category*

Referring Organisation*

Referring Organisation Name

Person Making Referral*

Referrers Tel No*

Referrers Email Address*

Client details

Please enter the details of the person requiring support

ClientType*

Client First Name*

Client Last Name*

Client Tel No*

Client Contact Details

If the survivor/victim does not reside in any of the listed districts, please contact us on 0300 0037777

Address Line 1

Address Line 2

Town

District*

Postcode*

Permission to Leave Voicemail*

Permission to Send Text*

Permission to Contact via Email

Permission to send Post

Alternative Safe Contact Details

Additional Details

Date of birth (dd/mm/yyyy)*

Age at Time of Assault

Client Ethnicity 1*

Client Ethnicity 2

Nationality

Immigration status

Primary language

Interpreter Required*

Marital status

No. of Dependants

Gender*

Sexuality

Religion

Employment status

Accommodation

Living with

Issues

Risks

Disabilities*

Please name any other organisations or workers involved

Further information or issues relevant to this referral*
(Has the survivor/victim been investigated for any sexual/violent offences?)

Are you aware if client has previously used our services?

Assault Details (if known)

Crime Ref No

Date of Assault (dd/mm/yyyy)

Date Reported (dd/mm/yyyy)

Reported to police

Police Force

Police Force detail

Police Investigating Officer

Presenting incident*

Alleged Perpetrator Name/Desc

Alleged Perpetrator Age

Alleged Perpetrator Relationship

Forensic Exam Date (dd/mm/yyyy) (dd/mm/yyyy)

Sexual Health Clinic Attended

Court case pending

Court Start Date (dd/mm/yyyy) (dd/mm/yyyy)

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

By submitting this form you understand that your data is processed in accordance with our privacy notice