Referral Form

WELCOME TO RASAC

Therapeutic Services

Our therapeutic services are available to people of any gender, over the age of 13, living in Kirklees Calderdale or Wakefield. We work with individuals who have experienced any form of rape or sexual abuse. We also work with individuals who have experienced domestic abuse within an intimate partner relationship. Our Therapeutic Team offer a wide range of support, including; Counselling, Art Therapy, Group Therapy, Support Sessions, our Helpline and Holistic Healing. Our Holistic support sessions include Yoga, Reiki and other groups focused on physical, mental, emotional, and spiritual wellness.

Required fields are shown in red. You will not be able to submit the form if you do not complete the mandatory fields.

Referral Information

Is this a Self Referral? Deselect if not a self referral

Client details

Please enter the details of the person requiring support

Client Pronouns

Client First Name

Client Last Name

Date of birth (dd/mm/yyyy)

Sex

Biological Sex registered at birth

Gender

Gender identity

Sexuality

Client Ethnicity 1

Client Ethnicity 2

Nationality

Immigration Status

Primary Language

Interpreter Required

Religion

Disabilities

Client Contact Details

District

Address Line 1

Address Line 2

Town

Postcode

Client Tel Number

Client Email

Permission to Leave Voicemail

Permission to Send Text

Permission to Contact via Email

Permission to send Post

Alternative Safe Contact Details

Additional Details

GP Surgery

Please name any other organisations or workers involved and provide their contact details

Employment Status

Accommodation

Living With

Dependants

Issues

Information you would like to share regarding the concerns or issues raised above

RASAC has workers of different genders, please tick who you would be comfortable working with.

Is the referral in relation to

(Domestic Abuse - RASAC is only able to support people who've experienced domestic abuse within an intimate partner relationship.)

Alleged Perpetrator Name/Desc

Alleged Perpetrator Relationship

Make a referral for Therapeutic Support Click in box to complete the details

Information Sharing

This data is stored in accordance with GDPR regulations and will be destroyed after seven years. It will not be shared with a third party unless we have your explicit consent to do so. We only keep data which is necessary. You are entitled to look at your records at any time. Please sign below to give your consent for us to keep this data. Please tick to give your consent (tick box)*