Organisation Referral Form

For professionals and agencies referring a client to Family Matters. Do not use this form for emergencies.

Before completing this form: Discuss the referral with the client wherever it is safe and appropriate to do so. Give them Family Matters' privacy information and explain what information you intend to share. Do not use this form for emergencies.

Immediate risk: If anyone is in immediate danger, contact emergency services. The referrer remains responsible for urgent safeguarding action and risk management until Family Matters confirms in writing that it has accepted the referral and any agreed responsibilities.

The client must be a resident of Kent or the London Borough of Bexley to access the available services.
Please complete all sections of this form.
Should any information not be completed your form will be returned to you and this will delay the referral being processed.
Please note, if the client is currently receiving therapy elsewhere, we are unable to offer our support at this time, as running concurrent therapy sessions is not suitable for effective progress.

Before You Begin

Family Matters is a trauma informed organisation providing specialist therapy services to victims and survivors of sexual violence and abuse in Kent and the London Borough of Bexley.

Please confirm the following before proceeding: I confirm that the person being referred is not subject to an ongoing police investigation for sexual, domestic, or violent offences, and is not known to pose a risk of harm to others. By ticking this box, I and the person being referred agree for checks to be made regarding their risk status. *

This form cannot be submitted without confirming the above.

Please read the following carefully before completing this form.

We will only accept referrals for individuals who have agreed to attend and are aware that this referral has been made
We do not accept referrals for anyone who is subject to an ongoing police investigation for sexual, domestic, or violent offences, or for anyone who may pose a risk of harm to others
Referring agencies must inform us of any known risks to or from the person being referred
We must be informed of the person's involvement with any other agencies, such as Social Services, Probation, or Mental Health Services – this is particularly important if the person is involved in care proceedings
We will not disclose information to the referrer about the service user's attendance or any issues discussed without written consent from all relevant parties, unless there are safeguarding concerns
Family Matters reserve the right to refuse the provision of services

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

Referrer Details

Referring Organisation Category

Referring Organisation

Referring Organisation Name

Person Making Referral

Referrers Tel No

Referrers Email Address

Applicant Contact Details

Please note, support is offered to clients residing in Kent and the London Borough of Bexley only.

Client type

Client First Name

Client Last Name

Date of birth (dd/mm/yyyy)

Address Line 1

Address Line 2

Town

Postcode

Client Tel Number

Alternative Safe Contact Details

Permission to Leave Voicemail

Permission to Send Text

Permission to Contact via Email

Permission to send Post

Client Email

Parent/Guardian Details

If this application is for a client aged 17 or under, please complete the Parent / Guardian Contact Details below.

Contact type

Contact Name

Address Line 1

Address Line 2

Town

Postcode

Address Permissions

Phone type

Phone number

Phone Permissions (please select all that apply)

Email Address type

Email address

Email Permissions

Client Details

Please complete this section as thoroughly as possible, as this information is used for data analysis and funding purposes, helping us to continue supporting the community.

Sex

Biological Sex registered at birth

Gender

Gender identity

Sexuality

Client Ethnicity 1

Client Ethnicity 2

Nationality

Immigration Status

Primary Language

Interpreter Required

Due to our current funding, we are unable to offer interpreter support for therapy sessions.

Marital Status

Religion

Employment Status

Accommodation

Living With

Dependants

Have you/are you aware if client has previously used our services?

Medical Details

Surgery Name

GP Name

Address

Phone Number

Email Address

Disabilities (please select all that apply – 'None' can be selected from the list)

Please provide any further information in the Further Information box further down the form. (If the client has seizures, please write what action should be taken in an emergency and their emergency contact details)

Medications relating to Mental Health (please select all that apply)

Medication details

Harm and Risk

Referrer responsibility: Give enough detail for safe triage. Where risk is current, record the action already taken and the professional/service currently responsible. This form does not replace your safeguarding referral, emergency response or internal reporting procedures.

Risks (please select all that apply – 'None' can be selected from the list)

Incident Impact (please select all that apply)

Has the client recently contemplated suicide?

Has the client recently self harmed in a serious or life threatening manner?

Please note if the client has harmed themselves or taken serious risks with their health we will need to write to their GP or Mental Health Professionals as part of our risk assessment.
If the client has thoughts of hurting or harming themselves we would urge them to contact their GP to discuss how they are feeling and seek support.
If the client feels they need help now they should call their GP, 111 out of hours or their mental health crisis team, or go to A&E. If the client has seriously harmed themselves they should call 999 or go straight to A&E.

Does the client take drugs that may affect their attendance/ability to function at sessions?

Does the client consume more than the recommended alcohol intake per week? (14 units)

To access support with FM the client will be required to be free from drugs or alcohol when attending sessions.

Is the client pregnant? If so, please provide their estimated due date

Has the client been cautioned or convicted of a criminal offence?

Please provide what offence was committed, what the sentence was and when did the offence occur

Mental Health

Please list all that apply ('None' can be selected from the list)

Mental Health Team Details

Is the client live with a Mental Health Team at the moment?

Organisation

Contact Name

Address

Phone Number

Email Address

Has the Client Experienced Abuse

We apologise for the delicate nature of some of these questions, however we need this information to ensure the best pathway for the client's support

Brief incident summary – please provide an outline of the circumstances leading to this application

Presenting incident

Incident occurences

Incident Start Date (dd/mm/yyyy)

Incident End Date (dd/mm/yyyy)

Age at Time of Assault

What is the abusers relationship to the client/survivor?

Is the client dependent on the abuser?

Does the client have any contact with the abuser?

If you have selected ‘yes’ to either of these questions, please provide details on how the client is dependent on the abuser, or what kind of contact they have with the abuser?

Sexual Health Clinic (SARC) Attended

SARC Attendance Date (dd/mm/yyyy)

Crime Reporting

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

Phone Number

Email Address

Court case pending

Court Start Date (dd/mm/yyyy)

Social Services

If the client is open with Social Services, please complete the below. If not, please move onto the next section.

Organisation

Contact Name

Address

Phone Number

Email Address

Social Services Involvement

Please name any other organisations or workers involved – including name and contact details of support workers

Further information or issues relevant to this referral

Please provide an outline of the circumstances leading to this referral and any additional information that may support service delivery, including details of the client's mental health, risk factors, or any potential safety considerations for the client or staff.

(Has the survivor/victim been investigated for any sexual/violent offences?)

(If the client has seizures, please write what action should be taken in an emergency and their emergency contact details)

Are there any safeguarding concerns, and if so, have they been actioned?

Availability

Family Matters is a registered Charity that provides free specialist support for all survivors of rape and sexual violence to residents of Kent and the London Borough of Bexley.
We offer the following support options. Please indicate which service the client requires. If you are unsure our team will call the client to discuss our services with them.

Therapy

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

Therapy

Sessions offered via telephone, video call or face to face.*

Please note – London Borough of Bexley clients must be 18 or over, due to funding restrictions we cannot see children or young people.

Please also note that clients residing in East Kent will be seen via videocall or telephone only due to our funding restrictions.

*Sessions offered via telephone or video call only for London Borough of Bexley residents who are 18 years old or over due to funding restrictions.

(Therapy available to Residents of Kent and London Borough of Bexley)

Does the client have a preference for face to face or online sessions?

Client's available times (please select all that apply)

Face to Face Therapy is available at the following venues. Please select up to 3 that the client can travel to, in order of preference (e.g. 1, 2 and 3)

Therapy Venue 1st choice

Therapy Venue 2nd choice

Therapy Venue 3rd choice

As a charity we have limited staff and availability at venues. Appointments are generally available Monday to Friday 9am to 5pm. Later appointments may be available, but should the client require this they may be asked to travel to a venue that has not been included in the choices. Therefore, the more availability the client has, the easier it will be to setup appointments and reduce their waiting time.

Statement of Confidentiality

Any information provided to Family Matters by the referrer will be treated as confidential unless stated otherwise. In order for us to provide an effective service, the information shared is confidential to the organisation as a whole, rather than to any individual member of staff. We will only collect the information necessary to enable us to offer an appropriate service to the client and to monitor and evaluate that service.

We do not share information with third parties without consent from the client, except in exceptional circumstances. These may include situations where there is a serious risk of harm to the client or others – for example, where there are concerns about the wellbeing of a child or vulnerable young person/adult, or where a third party may be at risk if information is not disclosed. While anyone may have associations with a gang, if the client’s involvement is linked to illegal activity such as trafficking, drug dealing, or violent crime, we have a duty to report this to the police or relevant safeguarding services.

To avoid requesting the same information more than once, Family Matters will keep certain records relating to the referral and the client. This may include information about the client’s health, care needs, family circumstances, or any other relevant details shared by the referrer or the client. All information will be stored securely and used only for the purpose for which it was provided.

If the client is not satisfied with the service provided, Family Matters operates a complaints procedure. Any concerns raised will be taken seriously and addressed appropriately. Information about this process can be obtained by contacting the Family Matters office on 01474 536661.

The client has the right to request access to the records we hold about them at any time, subject to reasonable notice. Identification may be required to verify their identity before information is disclosed.

If the referrer or client requires any further information about Family Matters’ confidentiality policy or how we comply with data protection legislation, please do not hesitate to contact us.

FM Contract Agreement

Please ensure you read this to/with the client as the client must be aware of the contract and consent agreement and agree to the terms.

Therapy is a commitment, which requires trust, honesty and continuity from both client and therapist. This work needs to be held within safe boundaries. The following is a contract to which both the client and FM agree:

Confidentiality

The client agrees that they can expect total confidentiality with the exception of:

Disclosure of self-harm or intention/act to harm others.
Disclosure of unreported abuse on a vulnerable person or a child under 18 or possible risk of abuse to others.
If a request is made by a Court or a person with parental responsibility, then Family Matters will have to provide records. If the Police request notes, we will seek the client's consent first.
FM may contact the appropriate medical professionals or other relevant agencies if required.
In cases where legal proceedings are ongoing therapy will follow the CPS pre-trial therapy guidelines, ensuring that sessions are supportive without compromising legal processes. Any request for therapy notes from legal entities will be discussed with the client and written consent will be required before disclosure unless mandated by law.

Sessions:

Sessions will last for 50 minutes.
There will be 12 therapy sessions, once a week, unless agreed otherwise.
If the client cannot attend an arranged session, they need to inform FM Office – 01474 536661 and give at least 3 days’ notice or the session will be counted.
If the client does not inform FM and misses a session, it will count as one of their 12 sessions.

Expectations:

If the client has withheld information, then FM reserve the right to end their engagement with the service.
The client must be willing to be free from drugs and alcohol whilst attending sessions with FM.
There is no social interaction outside the therapy.
The client must have read and understood the ‘Statement of Confidentiality’, or have had it read and explained to them.
The client agrees for Family Matters to store personal information in accordance with the General Data Protection Regulation (GDPR). (Information regarding the GDPR can be found in the Family Matters Privacy Policy as well as at www.ico.org.uk)
FM is a charity with limited resources and may not always be the most suitable service for the client and FM may, in their discretion, refuse or cease support.

Feedback:

It is important to Family Matters that service users are involved in the delivery of our service. We want to give the client the opportunity to tell us if they have experienced a problem. To seek improvements in our service the client's feedback is particularly relevant to us and the care they receive should be of a high standard. Our remit is to help improve the client's life and we don’t want them disengaging from therapy or support because they have a problem that they cannot share with us. The client can call us on 01474 536661 to discuss any problems they might have.

Consent

Please ensure you read this to/with the client as the client must be aware of the contract and consent agreement and agree to the terms.

So that we can work in a multi-disciplinary way and to ensure we offer a treatment plan that the client's support providers are in agreement with we kindly request further information from them including any relevant medical or mental health conditions and any suicidal or self-harm ideation. Further to this, we request they please advise us of any therapy or other support the client has received in the past few years in relation to this issue. If they have their own Risk Assessment document and are able to share it with us this would also be much appreciated.

Please be advised that we may not be able to continue with the application and risk assessment process until we have received this information from all the client's support providers.

Please note that if required, Family Matters may contact any of the following in order to complete our risk assessment. By submitting this application, you are confirming that the client agrees that FM may contact these providers, if required.

Early Help
Mental Health Services
Drug & Alcohol Support
GP
Social Services
Education Provider

Any personal information we receive is only used for the purpose of which you have been informed and only to complete this specific request for support. Please see our privacy policy for further information.

Referrer Declaration

By signing or submitting this form, I confirm that:

to the best of my knowledge, the information in this referral is accurate, relevant and up to date;
I have distinguished information known directly to me from information reported by others and from my professional opinion;
I have explained the purpose of the referral, the information being shared and Family Matters' role to the client in a way they can understand, wherever it was safe and appropriate to do so;
I have accurately recorded whether the client agreed to the referral and, where agreement was not obtained, the relevant legal or safeguarding basis for sharing the information;
I have shared only information that is necessary and proportionate for this referral and have used an appropriately secure method;
I have not used this referral as a substitute for emergency action, a safeguarding referral or my organisation's risk-management procedures;
where current risks are identified, I have recorded the action taken and the professional or service currently responsible for managing them; and
I understand that submitting this referral does not guarantee acceptance and does not transfer responsibility for the client or identified risks. My organisation will retain responsibility until Family Matters confirms any change of responsibility in writing.

Signed (please type your full name)

I confirm the referrer declaration above *

The client has consented to this referral *

By submitting this form you understand that the data provided is processed in accordance with our privacy notice