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ISVA referral form

Please note:

This form is for those seeking out ISVA services. If you are looking to refer to our counselling or groupwork services, please fill out this form.

Our ISVA service is only available to boys, men and non-binary people living in London or where the offence happened in London. If this does not apply to you, please email [email protected] with your location and we will try and find a service local to you. We will contact you within fifteen working days of receiving your referral.

If you are looking for an ISVA service for girls or women in London, please contact the London Survivors Gateway.

Section 1 - Referral Information

MM slash DD slash YYYY
If you prefer not to provide that information, please write N/A
If you prefer not to provide that information, please write N/A

Please only answer these questions if you are referring someone

MM slash DD slash YYYY
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

If you're referring yourself, don't worry about filling in this field.
MM slash DD slash YYYY
Do you identify as transgender *(Required)
Safe to call? *(Required)
Safe to email? *(Required)
Safe to write? *(Required)
Preferred method of contact?(Required)
Do you have a disability? *(Required)
Do you require an interpreter? *(Required)
Do you have a history of violence? *(Required)

Section 3 - Perpetrator Information

Type of sexual violence presenting experience *(Required)
If you are referring yourself, please answer this question as such.
When did the abuse take place? *(Required)
MM slash DD slash YYYY

Section 4 - Reason for Referral

Please provide a summary of the offence. Include any risks and the reason for referral if you are submitting the referral for someone.

Section 5 - Additional Information (e.g. best time to contact to the client, other support services involved, health issues, additional risks)

* Your details are safe with us - read our privacy policy

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