Referral Form: Organisation

RSACC has made the difficult decision to temporarily stop accepting any new adult referrals to our counselling service. While we regret having to make this decision, we do not feel we can fairly add new referrals to our waiting list until funding is secured to confidently provide the service beyond March 2026. Please look at our website for further information around the waiting list closure for our adult counselling service and for what support is available. We hope to be in touch with a further update in due course. In the meantime, if you require more information about our other services or alternative provisions, please get in touch with our team who are here for both you, and your clients. Please note we are still accepting counselling referrals for anyone who is 18 and under, our ISVA service and any of the Groups

Before you begin completing this online form please note we are happy to answer any questions you may have however, we do not provide a crisis service. In case of an Emergency please call 999.

IMPORTANT PLEASE READ: Before submitting a referral please pay attention to the Information within the Service Details section or take a look at our website ‘Get Help’ tab (all the services we provide), this will help you when choosing what service is right for you. If you are unsure about which service to refer to, then please feel free to contact the office on 01325 354 119 or email: info@rsacc-thecentre.org.uk.

We offer free, safe support to anyone over 13 who has experienced any form of sexual violence at any time in their lives.

We can accept referrals from clients who live, work or are accessing education in Darlington and County Durham.

Please note for Durham police referrals please do not use the form below and follow the correct referral pathway.

Please complete the below form with as much information as possible.

We will only accept referrals for those who are aware that the referral is being made.
Please confirm that the person being referred is aware of a referral (tick box)

Required fields are shown in red

Referrer Details

Referring Organisation Category

Referring Organisation

Referring Organisation Name

Essential Details

Person Making Referral

Referrers Tel No

Referrers Email Address

Client type

Client First Name

Client Last Name

Client Tel No

Client Email Address

Service Details

Please select one of the options below

Services

Explanation of services (Click here to show/hide details)

Client Contact Details

Address Line 1

Address Line 2

Town

District

Postcode

Permission to Leave Voicemail

Permission to Send Text

Permission to Contact via Email

Permission to send Post

Alternative Safe Contact Details

Additional Details

Date of birth (dd/mm/yyyy)

Age at Time of Assault

Client Ethnicity 1

Client Ethnicity 2

Primary Language

Interpreter Required

Sex

Biological Sex registered at birth

Gender

Gender identity

Sexuality

Religion

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?

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

Officer rank

Officer First Name

Officer Last Name

Officer Collar Number

Presenting incident

Alleged Perpetrator Name/Desc

Alleged Perpetrator Relationship

Alleged Perp Age Now

Alleged Perp Age at Assault

Forensic Exam Date (dd/mm/yyyy)

Sexual assault referral centre attended

Court case pending

Court Start Date (dd/mm/yyyy)

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