BIRCHALL REFERRAL FORM – SELF REFERRAL

This form is for survivors and their supporters to refer themselves for support. If you are a professional working with agency and would like to refer a client, please click here.
Please note we do not provide a crisis service, in emergency please contact 999.
If you are unsure if your referral is suitable or have any further questions please contact us on 01229 820828 or 01524 239595 before completing this referral form

IMPORTANT PLEASE READ:

If you have experienced sexual violence or abuse at any time in your life and are looking for help and support then please complete the form below

If you have recently been assaulted you may wish to consider contacting :-

The Bridgeway Service in Penrith (Cumbria) or The Safe Centre in Preston (Lancashire)

We are able to offer services to:

Adults, Children and Young people living in Cumbria and Lancashire and surrounding areas
People of all genders
Children and Young people aged 4 and above
People who have experienced some form of sexual violence or abuse in their lives
People who consent to being contacted by us to discuss their support options in relation to their experience of sexual violence/abuse specifically

Confidentiality

Our service is bound by a strict code of ethics around confidentiality. All our services work to ensure the highest levels of confidentiality, extending to how we store any information and we are governed by GDPR rules.

However, there are exceptions where there is a moral and/or legal duty to breach confidentiality and this applies to any information shared at the referral stage including;

Prevention of serious harm to the individual or another person.
Certain child protection situations.
Knowledge of acts of terrorism or another illegal act.
Human trafficking.

We are a survivor focused organisation and as such we do not accept referrals for anyone who is subject (the suspect) to an ongoing police investigation for sexual or violent offences, or for anyone who may pose a risk of harm to others.

Please confirm that you do not pose a risk of harm to others, and are not known to Police regarding violent or sexual offences (tick box)*

Information submitted on this referral form will be treated as confidential and stored securely on the Birchall Trust’s 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.

Required fields are shown with a *

Details of the person who would like support

Client First Name*

Client Last Name*

ClientType*

Date of birth (dd/mm/yyyy)*

Age at Time of Assault

Client Ethnicity 1*

Client Ethnicity 2

Nationality*

Immigration status

Primary language*

Interpreter Required

Gender Identity*

Trans identity or history

Do you identify as trans or having a trans history?

Sexuality*

Religion

For example, risk to self or others, risk from perpetrator(s), involved in MARAC, child protection, relationship breakdown, homelessness

Disabilities*

Marital status

Contact details

Address Line 1*

Address Line 2

Town*

District*

Postcode*

Client Tel No*

ClientEmailAddress*

Permission to Leave Voicemail*

Permission to Send Text*

Permission to Contact via Email*

Permission to send Post*

Alternative Safe Contact Details

Emergency contact details

Contact Name*

Relationship*

Phone Number*

Email Address

Additional details

GP*

Employment status

Accommodation

Living with*

Issues*

For example issues around dependencies, mental health, domestic abuse, self-harm

Risks*

Are you involved with any other agencies or organisations?

Further information or issues relevant to this referral

Dependents

Dependant 1

DependantName1

DependantGender1

DependantDateOfBirth1

Dependant 2

DependantName2

DependantGender2

DependantDateOfBirth2

Dependant 3

DependantName3

DependantGender3

DependantDateOfBirth3

Incident 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*

(CSA means 'Childhood Sexual Abuse')

Alleged Perpetrator Name/Desc

Alleged Perpetrator Age

Alleged Perpetrator Relationship

Forensic Exam Date (dd/mm/yyyy)

Sexual Health Clinic Attended

Open to Court*

Court Start Date (dd/mm/yyyy)

Service Details

Please select which service you would prefer to access.

Please note that based on need and risk we may not offer your client their initial selection.

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

Adult Counselling

We offer trauma informed counselling to survivors of rape and sexual abuse aged 18+ provided by qualified counsellors and counselling students in their final year of placement. Counselling takes place on a weekly basis and may be short or long-term depending on the individuals’ needs. Supporters and carers of survivors may also access this service if they have been affected by the survivors’ experience of sexual violence or abuse..

Children/Young People Counselling

We use creative therapeutic approaches such as play, sand, clay, musical instruments, puppets, books and art therapy to help children and young people aged 4+ to explore their feelings, express themselves and make sense of their life experiences. Weekly sessions allow children and young people to understand their feelings and thoughts, manage relationships and conflicts in appropriate ways.

Wellbeing

Our Trauma Informed Wellbeing practitioners work with individuals on their specific needs to maintain and improve their wellbeing, over a period of 6 -12 weeks – this will be different for everyone as the work is person-centred to ensure we have a holistic approach to empower them to take control of their wellbeing. They offer psychoeducation to allow people to understand their mind, body and behaviours during and after trauma.

Pre-Trial Therapy

We offer 12 weeks therapy to victims or witnesses while a criminal justice process is ongoing and a trial may be possible. This is limited therapy to support people emotionally, building confidence and self-esteem, explore worries and concerns and identify support systems. Due to the nature of the work, counsellors and wellbeing practitioners will not be able to discuss the actual event relating to the criminal justice process.

Groups

Our peer support groups have been designed to provide a weekly safe space for adult survivors of rape, sexual exploitation and sexual abuse as a child or in adult life to come together to talk, listen, share and learn from one another in a confidential setting.

In your own words, tell us why you want to come to Birchall*

Have you used our services before?*

Do you have a preference for a male or female worker?*

Do you have a preference for face to face or online sessions?*

Are you willing to work with a student counsellor?*

If the referral is for a child or young person are you/they involved in Children’s Services?*

Other Services involved*

Has parental consent been granted for this referral (if under 13)*

Contact details of any professionals involved

ContactType1

ContactName1

Address details and contact number

ContactType2

ContactName2

Address details and contact number

ContactType3

ContactName3

Address details and contact number

Thank you for submitting your referral form. You can expect contact from us within the next 48 hours. We’ll ask you to reach out to schedule an assessment appointment, which will take about 40 minutes.

For your comfort and privacy, we kindly ask that you find a quiet and confidential space for the call. We look forward to speaking with you soon.