Referral Form

Please complete the form with as much information as possible.

Welcome to our online referral form

We offer: therapeutic support (specialist sexual violence support + counselling)
advocacy support (ISVA + ChISVA)

To: Anyone who has experienced any form of sexual violence at any point in their life

Who lives, works or studies in Lincolnshire
We support all ages and all genders
We also support those who are at risk of sexual violence, and those impacted by it (supportive family, friends and professionals)

We will only accept referrals for those who are aware that their information is being referred to us. For young children, consent can be given by a safe parent/carer. Please tick this box to confirm this. *

We are a survivor focused organisation, and we do not accept referrals for anyone who is subject (the suspect) to an ongoing police investigation for sexual, domestic, or violent offences, or for anyone who may pose a risk of harm to others. By ticking this box, you and the person being referred agree for checks to be made regarding their risk status.

I hereby confirm, based on my professional judgment and assessment of risk, that the individual being referred does not pose a threat of harm to the clients or staff members of Lincolnshire Rape Crisis. Please tick this box to indicate your confirmation. *

LRC reserve the right to refuse the provision of services. If you are unsure of the suitability of our services for the person that you are referring, please call us on 01522 716320 to speak to a Navigator.

Referral: Once submitted, our team will attempt to contact the client within 2 working days to book in their telephone assessment. We will contact them via telephone first and by email if we are not successful. We will email you to confirm receipt of your referral.

Referring agencies must inform us of any known risks to or from client.
We will not disclose issues discussed without the written consent of the client, unless there are safeguarding concerns.
We must be informed by the referrer of the client’s involvement with other agencies e.g. Social Services, Probation Services or Mental Health Services. This is particularly important if the client is involved in care proceedings.

Required fields are shown in red.

Service Details

Service being referred into

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

Client Contact Details

Address Line 1

Address Line 2

Town

District

Postcode

Permission to Leave Voicemail

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

Nationality

Immigration status

Primary language

Interpreter Required

Marital status

No. of Dependants

Gender

Sexuality

Religion

Employment status

Accommodation

Living with

Issues (Please note, more than one Issue can be added)

Risks (Please note, more than one Risk can be added)

Disabilities (Please note, more than one Disability can be added)

Please name any other organisations or workers involved

Any further information or risks that you feel are relevant to this referral

Are you aware if client has previously used our services?

How did you hear about us?

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

Assault Details (if known)

Presenting incident

Date of Assault (dd/mm/yyyy)

Alleged Perpetrator Name/Desc

Alleged Perpetrator Age

Alleged Perpetrator Relationship

Forensic Exam Date (dd/mm/yyyy)

Sexual Health Clinic Attended

Open to Court

Court Start Date (dd/mm/yyyy)

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