Referral for Adult Services (Professionals)

This referral form is for professionals wishing to refer their clients and should be used only where individuals do not wish to report their experience to the Police.

Our ISVA service supports clients who have recently reported or who are considering reporting their experience to the police, referrals to the ISVA service can be made here.

Does the client you are referring for support have any recent convictions (within the last 5 years) for any violent or sexual offences? If yes, please call us on 01226 320140 to discuss. If no, please fill in the remainder of the form.

* Denotes a required field

Referrer Details

Professional Name

Professional contact number

Professional email address

Professional organisation

GDPR * – We record and retain the personal information submitted on this form for the purpose of referral management, please tick this box to confirm that you understand and agree to us retaining your data for this purpose. You can request, at any time, that we remove your personal information from our records.

Client Details

Client name *

Client date of birth (DD/MM/YYYY)*

Client contact number

Can we text this number?

Yes

Unsure

Can we leave a voicemail on this number?

Yes

Unsure

Client Address

Can we write to this address?

Yes

Unsure

Can we write to this address on headed paper?

Yes

Unsure

Client Email Address

Are there any other services your client is currently accessing?

Yes

Unsure

If yes please tell us who

Has your client had any previous support which they found helpful or unhelpful?

Yes

Unsure

If yes please briefly outline

Are there any days or times we need to avoid? Work/School Run etc

Was the incident ever reported?

Yes

Unsure

How is the incident impacting on your client’s life? For example anxiety, flashbacks, nightmares, not going out

What support mechanisms does your client have in place?

Our funders require demographic information people accessing our service, we provide this information to them anonymously. It would help us enormously if you could provide the information requested below:

Gender

Sexuality

Ethnicity

Religion

Does your client have a physical disability?

Yes

Unsure

Accessibility

My client would prefer to see

Does your client have any additional needs such as i.e large print, translator, spoken communications?

If you are able to can you tell us a short summary of what has happened?

Is there anything else you feel is relevant to this referral?

Once we receive this form we will be in touch with the client directly

We will add your client to our waiting list. For wellbeing and counselling we have a lengthy waiting list and it is unlikely we will be in touch before an appointment becomes available.

RCEW Helpline 0808 802 9999 (women and girls)
Safeline 0808 800 5005 (men)
Samaritans 116 123

In an Emergency call 999