Self Referral Form

Before you begin

Thank you for accessing the SARSVL ISVA Service Referral Form.

Before you begin completing this online form please note we are happy to answer any questions you may have. You can call our office on 0113 243 9102. However, we do not provide a crisis service. If you are in immediate danger, please dial 999.

Self-referring means you can contact us directly to access support.

SARSVL can provide a safe space for you to talk about how rape or sexual violence has affected you and we can help you to explore your options. We offer a specialist counselling service; an ISVA service which offers support if you have reported to the police, or are considering doing so; and our anonymous Helpline offers emotional support by phone, text or email. This form is for the ISVA service only.

Independent Sexual Violence Advocate

About:

Our ISVAs are trained in providing specialist trauma informed emotional and practical support to women and girls (aged 13 +) who have reported sexual violence to the police, or are considering doing so. ISVA support is offered throughout the police investigation, and beyond, if the case gets to court.

At SARSVL we have ISVA’s who support women aged 18 and over, and a specialist Young Person’s ISVA who supports young people aged between 13 and 17.

We offer appointments to suit your needs - they can be face to face in our Leeds Office, online, or over the phone. For young people aged between 13 and 17 we can offer outreach appointments such as in your school or college.

Criteria:

Women and girls (aged 13 +) resident in the Leeds area.

To self-refer, fill out the information, and click the “Submit” button at the end of the form.

Once we have received your details from this form, we will contact you within 3 workings days, to obtain more information in order to process your referral.

SARSVL aims to offer a confidential service. Your data is stored in accordance with GDPR regulations and will be destroyed after 7 years. However, if we are concerned about your welfare, or the welfare of others, then we may need to share information with appropriate external agencies. Please tick the box below to give your consent for us to keep this data.

I consent

Required fields are shown in red. You will not be able to submit the form if you do not complete the mandatory field and tick the above tick box relating to consent.

Main details

Please enter your name details

Client type

First Name

Last Name

Gender

Gender identity

Date of birth (dd/mm/yyyy)

Contact Details

If you do not reside in any of the listed districts, please contact us on 0113 243 9102

District

Address Line 1

Address Line 2

Town

Postcode

Phone Number 1

Phone Number 2

Alternative Safe Contact Details

Permission to Leave Voicemail

Permission to Send Text

Permission to Contact via Email

Permission to send Post

Additional Details

If the survivor/victim does not reside in any of the listed districts, please contact us on 0113 243 9102

Person is aware?

If you are completing this form on behalf of someone else, please provide your name, and relationship to the person being referred in the comments box below. Please note we can only accept this referral if the person being referred is aware, and consents to the referral being made.

Please enter any comments below

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