Survivor Space Oxfordshire Referral Form

For professionals referring someone for support

Before you begin

Please complete this form with as much information as possible. If there is a question the person being referred feels uncomfortable answering here, you can leave it blank and discuss with us later.

You must have the consent of the survivor to make a referral on their behalf.

If you need support to complete this form, please contact us on 01865 965201 or referrals@survivorspace.org.uk.

Data Protection

The person's information will be kept safe and treated with care and respect. Personal information is confidential and will not be shared with anyone outside of Survivor Space without explicit consent, in line with the principles of the Data Protection Act 2018, unless there is a legal obligation or safeguarding concern/risk.

Required fields are shown in red.

Referrer

Referrer Type

Referrer Type 2

Referring Organisation Name

Person Making Referral

Referrers Tel No

Referrers Email Address

Person Being Referred

First Name

Last Name

Date of birth (dd/mm/yyyy)

Tel No

Email Address

Alternative Safe Contact Details

Address Line 1

Address Line 2

District

Postcode

Permission to Leave Voicemail

Permission to Send Text

Permission to Contact via Email

Permission to send Post

GP Name / Practice or Surgery Name

Ethnicity 1

Ethnicity 2

Ethnicity 3

Primary language

Interpreter Required

Gender

Sexuality

Religion

Employment / Education Status

Disabilities

Additional Notes

Dependants

Any children and any adults who are dependent on the person's care.

Dependant 1 Name

Gender

Date of birth (dd/mm/yyyy)

Dependant 2 Name

Gender

Date of birth (dd/mm/yyyy)

Dependant 3 Name

Gender

Date of birth (dd/mm/yyyy)

Experience(s) of Sexual Violence

Which of the following best describes the abuse/assault?

Reported to police

Crime Ref No (required if Referrer is Police)

What is the perpetrators relationship to the client?

Alleged Perpetrator Name

Service Information

Please select the most appropriate service. If unsure, click the explanation below.

Therapeutic Service

Independent Sexual Violence Advisor (ISVA)

Service criteria / explanation (click here to show/hide details)

We only accept self-referrals for our adult counselling service. We no longer accept referrals from professionals, agencies, or other organisations.

Young People Counselling Service

Specialist 1-1 counselling for young people aged 12 - 18 years old.

Independent Sexual Violence Advisor (ISVA)

Our ISVAs offer practical and emotional support for survivors who are considering reporting an experience of sexual violence, or who have already reported to the police. They can offer support with the reporting process, accompanying to meetings, and advocate on a survivor's behalf with the police and other agencies. We can also sometimes provide practical support with other issues related to the sexual violence you have experienced - e.g. housing, employment etc.

Brookes University ISVA service – students at Brookes University
Community ISVA service – survivors across Oxfordshire
Disability ISVA service – survivors with a disability in Oxfordshire
Domestic Abuse ISVA service – survivors who have experience domestic abuse in the last 6 months
Older Adult ISVA service – survivors 60+ in Oxfordshire
Oxford University ISVA service – students at Oxford University
Young People ISVA service – ages 12-21 across Oxfordshire

Specialist Outreach Support

Psychoeducation, emotional and practical support for survivors who do not want to report to the police. This service is for survivors who have support needs and experience additional barriers to accessing support, such as being vulnerably housed, having multiple/complex support needs, mental health needs, or from marginalized communities.

Groups

The groups are open to women and non-binary individuals recorded female at birth over the age of 18 who have experienced sexual abuse or rape, whether in the past or recently, as a child or as an adult. Please detail which group you would like to join in the additional information box below.

NOTE: Waiting times will vary from service to service due to the demand and number of people on the waiting list. Individuals may be offered an alternative ISVA service to the one selected (e.g. individuals with a mental health disability may be supported by the Community ISVA).

Additional Information

Further information or issues relevant to this referral

Please tick the box to confirm consent has been given for this referral to Survivor Space services and agreement to Survivor Space's privacy policy.