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Referral Form

Thank you for accessing the Synergy Essex organisation referral form.

If you wish to contact us by telephone please call 0300 003 7777 and speak to one of our staff:

  • SOSRC Centre: press 1 for: Southend, Castle Point, Rochford
  • SERICC Centre: press 2 for: Thurrock, Basildon, Brentwood, Harlow, Epping
  • CARA Centre: press 3 for: Chelmsford, Colchester, Braintree, Uttlesford, Maldon, Tendring

Before you begin

We are a victim focused organisation and as such 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. Please confirm that the person being referred does not pose a risk of harm to others, and is not known to Police regarding violent or sexual offences (tick box)*  

This referral cannot be submitted unless the above information is confirmed. By ticking this box, you and the person being referred agree for checks to be made regarding their risk status. Essex Rape Crisis Partnership reserve the right to refuse the provision of services.

Please complete the below form with as much information as possible. We may only disclose information to the referrer about the service user’s attendance with written permission from all parties.

We will not disclose issues discussed without the written consent of the service user.

We will only accept referrals for those who have agreed to attend and who are aware that the referral has been made.

  • Referring agencies must inform us of any known risks to or from the service user.
  • We will not disclose issues discussed without the written consent of the service user unless there are safeguarding concerns.
  • We will provide specialist services to victims and survivors of sexual violence and sexual abuse.
  • We will provide specialist services to family and supporters of victims and survivors.
  • We must be informed by the referrer of the service user’s involvement with other agencies e.g. Social Services, Probation Services or Mental Health Services. This is particularly important if the service user is involved in care proceedings.

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

Referrer Details

Client details
Please enter the details of the person requiring support

Client Contact Details
If the survivor/victim does not reside in any of the listed districts, please contact us on 0300 0037777

Additional Details

Biological Sex registered at birth
Gender identity
(Has the survivor/victim been investigated for any sexual/violent offences?)
Assault Details (if known)

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