Referral Form

For professionals with clients who would like support from SV2

Before you begin

We are a victim focused organisation and as such we do not work with perpetrators of sexual, domestic or violent offences.

We are unable to offer Therapy if the person you are referring still lives or is in a relationship with the accused perpetrator.

If you would like further information please contact the team on 01773 746115 to discuss support available.

THANK YOU FOR REFERRING TO SV2.

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. The form will be sent via a secure connection (SSL), which is encoded and goes straight into our database, accessed by SV2 staff only.

You can see our privacy notice at https://www.sv2.org.uk/client-privacy-policy.php

Before submitting a referral please read the service criteria/explanation within the service details section below, this will help you to decide which service or services will most benefit the person you’re referring.

Upon receipt of the referral we aim to make contact with the survivor 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

Support required

Please refer to our website for further definition of services available.

Independant Sexual Violence Advice

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

Essential Details

Person Making Referral

Referrers Tel No

Referrers Email Address

Client type

Client First Name

Client Last Name

Date of birth (dd/mm/yyyy)

Client Contact Details

Client Tel Number

Client Email

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

GP Details

Sex

Biological Sex registered at birth

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

Recent suicide attempt

Recent suicidal thoughts

Recent self harm

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

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)

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