Section 1 - Referral Information Please only answer these questions if you are referring someone Referral agency type Referral agency type* Friend/Family/Third Party Home Police Force British Transport Police Other Police Other Criminal Justice Agency SARC Adult Mental Health Services CAMHS Sexual Health Services Other NHS services Local Authority Educational Voluntary Sector Services Other Has the client consented to a referral being made to SurvivorsUK? Is the client a victim/witness in a criminal case? Have you carried out a risk assessment on this client? Section 2 - Your Information Ethnicity (Required) Asian Bangladeshi Asian British Asian Indian Asian Pakistani Asian Other Black African Black British Black Caribbean Black Other White British White European White Irish White Other Irish Traveller Roma/Gypsy Chinese Latin American Middle Eastern North African White and Asian White and Black African White and Black Caribbean Any other dual or mixed background Other Prefer not to say Sexual orientation (Required) Heterosexual Bisexual Gay Lesbian Queer Asexual Pansexual Unsure/questioning Other Prefer not to say Gender identity (Required) Male Female Non-binary Intersex Unsure/questioning Other Prefer not to say Do you identify as transgender? (Required) Safe to call? (Required) Safe to email? (Required) Address
(Required) Safe to write? (Required) Preferred method of contact? Please select any of the following that apply to you: Do you have a disability? (Required) Do you require an interpreter? (Required) Do you have a history of violence? (Required) Section 3 - Offender Information If you are referring yourself, please answer these question as such. What is/was the relationship between you and the offender? (Required) Stranger Partner Ex-partner Acquaintance Family member Friend Work colleague Multiple perpetrators Other What was/is the form of sexual violence? (Required)
If you are referring yourself, please answer this question as such.
When did the abuse take place? (Required) Have you reported the incident to the police? Yes No Does the offender know where you live? Yes No I don't know Section 4 - Reason for Referral Section 5 - Additional Information Please provide any further details that you think it would be useful for the ISVA team to know
e.g. best time to contact to the client, other support services involved, health issues, additional risks