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Third party referral form

Please note:

Our ISVA service is only available to boys and men living in London or where the offence happened in London.

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

Section 1 - Referral Agency Information

If you prefer not to provide that information, please write N/A
If you prefer not to provide that information, please write N/A
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 - Client Information

Do they identify as transgender *(Required)
Safe to call? *(Required)
Safe to call? *(Required)
Safe to write? *(Required)
Does the client have a disability? *(Required)
Are there any additional vulnerabilities e.g. immigration status, language support, substance misuse? *(Required)
Does the client require an interpreter? *(Required)
Does the client have a history of violence? *(Required)

Section 3 - Alleged / Perpetrator Information

Type of sexual violence presenting experience *(Required)
When did the abuse take place? *(Required)

Section 4 - Reason for Referral

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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