SurvivorsUK | ISVA Self Referral Form

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ISVA Self Referral Form

If you are looking to refer to our individual counselling or groupwork counselling service, please complete the form via this link.

Please note that our ISVA service is only available for boys, men, and non-binary people living in London or where the offence took place 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.

Section 1 - Referral Information

Date of Referral

DD slash MM slash YYYY

Name of contact person(Required)

Contact phone number(Required)

Contact email address*(Required)

Name of next of kin(Required)

If you prefer not to provide this information, please write N/A

Contact details for next of kin(Required)

If you prefer not to provide this information, please write N/A

Please only answer these questions if you are referring someone

Referral agency type

Collar number

Police station

Crime reference number

Date of crime

DD slash MM slash YYYY

Has the client consented to a referral being made to SurvivorsUK?

Yes

No

Is the client a victim/witness in a criminal case?

Yes

No

Have you carried out a risk assessment on this client?

Yes

No

Please provide details of the outcome of the risk assessment

What level do you estimate the risk is?

Section 2 - Your Information

Name of client

If you're referring yourself, don't worry about filling in this field.

Date of birth(Required)

DD slash MM slash YYYY

Ethnicity(Required)

Sexual orientation(Required)

Gender identity(Required)

Do you identify as transgender?(Required)

Yes

No

What are your pronouns?

Contact details

Contact phone number

Safe to call?(Required)

Yes

No

Contact email address

Safe to email?(Required)

Yes

No

Contact Address(Required)

Street Address Address Line 2 City County Post Code

Safe to write?(Required)

Yes

No

Preferred method of contact?

Phone

Email

Letter

How did you you hear about SurvivorsUK's services?(Required)

GP details

Name of your GP

Your GP Address

Street Address Address Line 2 City County Post Code Country

Please select any of the following that apply to you:

Mental health issues

Substance/alcohol misuse

Learning disability

Physical disability

Pending immigration status

Additional language support

Other

Please give brief details of any of the above you have selected

Do you have a disability?(Required)

Yes

No

If yes, please give details

Do you require an interpreter?(Required)

Yes

No

If yes, what language?

Do you have a history of violence?(Required)

Yes

No

If yes, please give details

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)

Are you at risk from the offender?(Required)

What was/is the form of sexual violence?(Required)

Rape

Sexual assault

Sexual exploitation

Trafficking/sex work

Multi-perpetrator rape

Sexual harassment

Period of sexual abuse

Other

If you are referring yourself, please answer this question as such.

When did the abuse take place?(Required)

Within the last 12 months

Longer than 12 months ago

Childhood abuse

Please provide a date of the incident, if you are able

DD slash MM slash YYYY

Where did the incident take place?

Have you reported the incident to the police?

Does the offender know where you live?

Section 4 - Reason for Referral

Please provide the 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

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

Δ

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Our Helpline is open today, however we will be closed between 4pm- 4.30pm

1:1 chat sessions with trained support workers, in confidence.

We are here for any man, boy or non-binary person who has ever experienced unwanted sexual activity (such as words, images or touch). We are also here for loved ones supporting a survivor in their lives.

To learn more about our privacy and confidentiality policy click here.

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Info Leaflets and Cards

Please find a selection of useful SurvivorsUK materials below, which can be downloaded via the Download links.

SurvivorsUK Business Cards

A Guide to Our Services – Leaflet

Dancing With Our Ancestors – Poetry & therapy booklet by Black, Asian and Mixed heritage survivors

Training

SurvivorsUK offers professional training on providing services to male survivors and the impact of sexual abuse and rape on men and boys. We offer this training to individuals and organisations at competitive rates from our premises in East London or, depending on numbers, at a rented space nearby.

To make a booking please complete the booking form and email it to [email protected], or call 020 3598 3898.

Upcoming Training Events

Bespoke Training

Depending on availability, we may be able to offer bespoke training packages to organisations at your premises.

Trainer: Dr Katherine Cox
Lunch provided.

Rates

Large organisations £150 per person (or £120 pp for 3+ bookings)
Small organisations or individuals £100 per person (or £75 pp for 3+ bookings)

Dates

Saturday 23 May 2020
10am to 4pm

Enquire about this course

No training events are currently planned

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