Referral Form: Organisation

Professional Referral Terms

Please read the following information before continuing with this referral:

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

Please consider referring to:

Lucy Faithfull Foundation – Preventing child sexual abuse – https://www.lucyfaithfull.org.uk/
Help For Domestic Violence & Abuse Perpetrators | Respect UK – https://respectphoneline.org.uk/help-for-perpetrators/
Sunrise Therapy Service | Barnardo's – https://www.barnardos.org.uk/get-support/services/sunrise-therapy-service

ARCH Teesside Counselling Service provides therapeutic support for anyone in Middlesbrough, Stockton and Hartlepool who has experienced rape or any form of sexual abuse at any time in their lives and is struggling to cope with their feelings and emotions in relation to these experiences.

We also offer support to Men and Boys from Redcar and Cleveland.

We work in partnership to support the needs of Children and Young People. Consideration will be given as to the appropriateness of the referral.

Therapy can be hard work and extremely challenging, especially in the early days. It is therefore important that you consider the appropriateness of ARCH for the client’s needs before making a referral.

For example, we are unable to provide emergency crisis support or work with complex or severe mental health issues. Please speak to our referrals team on (01642) 822335 to discuss needs and appropriateness if you are unsure.

We are unable to accept referrals for individuals who:

Are currently experiencing a mental health crisis
Are actively suicidal or have attempted suicide within the last 3 months
Are currently an inpatient under Secondary Care Mental Health Services
Who have had multiple admissions or discharges from Secondary Care Mental Health Services within the past 12 months.

In the best interests of the person being referred, consideration should be given to specialist services for anyone who is struggling with issues relating to substance misuse.

The form will be sent via a secure connection (SSL), which is encoded and goes straight into our database, accessed by ARCH staff only. Please complete the form below with as much information as possible and ensure that the person you are referring is aware and has consented to the referral. Upon receipt of the referral we aim to make contact with the victim/survivor/supporter as soon as possible and this is usually within 5 working days.

Required fields are shown in red

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

Client type

Client First Name

Client Last Name

Date of birth (dd/mm/yyyy)

Service Details

Please read the service criteria above, then indicate which service(s) the referral is for. Please select at least one.

Advocacy (ISVA)

Counselling

Client Contact Details

If the survivor/victim does not reside in any of the listed districts, please contact us on 01642 822331

Client Tel Number

Client Email

District

Address Line 1

Address Line 2

Town

Postcode

Permission to Leave Voicemail

Permission to Send Text

Permission to Contact via Email

Permission to send Post

Alternative Safe Contact Details

Additional Details

Gender

Gender identity

Sexuality

Client Ethnicity 1

Client Ethnicity 2

Nationality

Immigration Status

Primary Language

Interpreter Required

Marital Status

Religion

Employment Status

Accommodation

Living With

Dependants

Non Statutory/Statutory Interventions

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)

Presenting incident

Age at Time of Assault

Date of Assault (dd/mm/yyyy)

Reported to police

Date Reported (dd/mm/yyyy)

Crime Ref No

Police Force

Police Force detail

Officer rank

Officer First Name

Officer Last Name

Officer Collar Number

Alleged Perpetrator Name/Desc

Alleged Perpetrator Relationship

Alleged Perp Age Now

Alleged Perp Age at Assault

Forensic Exam Date (dd/mm/yyyy)

Sexual Health Clinic Attended

Court case pending

Court Start Date (dd/mm/yyyy)

I confirm that the person being referred does not pose a risk of harm to others and is not known to the police regarding violent or sexual offences.

By ticking this box, I / the person being referred agree for checks to be made regarding their risk status.

ARCH Teesside reserve the right to refuse referrals and the provision of services. All relevant risk and need information should be sent with the referral. Contact 01642 822335 for more information. This referral cannot be submitted unless the above information is confirmed.