Online Agency Referral Form v2

Referrer Details

Are you referring your client into the ISVA Service:
YesNo
Are you referring from a SARC:
YesNo

How should we contact you?

Permission to leave you a phone message*:
YesNo
Permission to write to you*:
YesNo
Your preferred contact method:
PhoneEmailLetter

Client Details

How should we contact your client?

Permission to leave the client a phone message*:
YesNo
Are we allowed to leave a message on call-screening services on their phone?*:
YesNo
Permission to write to the client*:
YesNo
Permission to send text to the client*:
YesNo
Permission to contact via email*:
YesNo
Client's Preferred contact method:
PhoneEmailLetter
Best time to call
AMPMEvening

Please note that calls from our service show as a “Private number”

Please tell us if there are any restrictions contacting them.

About the Client

GP details are required for safeguarding purposes to access our support. We will be sending a letter to the client’s GP to inform them that they are accessing our service.

Is your client involved with other voluntary/statutory agencies?
YesNo

Does your client consent to share information with this person?
YesNo
Is there any risk from abuse now?* 
YesNo

Do they have any disabilities?*
Learning DifficultiesNeurodivergencePhysical DifficultiesMobility IssuesMental Health DifficultiesHearing impairmentSight impairmentCognitive impairmentLong-term Health ConditionsNoneOther
Do they have any additional requirements?*
Sign LanguageHearing LoopWheelchair AccessMedical ConditionGuide or Support DogOther requirements (i.e., ground floor access)None
What is their gender?*
MaleFemalePrefer not to sayNon-binaryOther

Is the gender you stated the same as the one they were assigned at birth?*
YesNoPrefer not to say
What are their pronouns?*
She/herHe/himPrefer not to sayThey/themOther

How would they describe their sexuality? *
Heterosexual/StraightBisexualLesbianPrefer not to sayGayPansexualAsexualOther

What is their ethnicity?*
Select...White EnglishWhite WelshWhite ScottishWhite Northern IrishWhite IrishGypsy or TravellerAny other White backgroundWhite and Black CaribbeanWhite and Black AfricanWhite and AsianAsian BangladeshiAsian IndianAsian PakistaniAsian ChineseAny other Asian backgroundBlack African Black or Black BritishBlack CaribbeanAny other Black backgroundAny other Mixed or Multiple backgrounds
Do they have any religious beliefs? *

BuddhistCatholicChristianHinduIslamJudaismSikhNo ReligionOtherNot stated

Do they have any immigration-related issues that affect their access to services?
YesNo

Does your client require an interpreter?
YesNo

What is their occupation?
Select...Employed Full-timeEmployed Part-timeUnemployedNon-advanced education (e.g., GCSEs, A-Levels)Nottingham Uni StudentNTU StudentOut of Area StudentUndisclosed Uni StudentSelf-employedUnable to work (health/disability)Carer / HomemakerRetiredOther

Which of the following best describes their current accommodation? *
Select...Permanent accommodationSupported accommodationTemporary accommodationOther

Are they currently pregnant or have they had a baby in the last 12 months? *
YesNoPrefer not to say

Do you have any children under 18 years old?

We ask this to help us understand your circumstances and ensure we offer safe and appropriate support. You can choose not to answer this now if you prefer, however you will be asked about this during your assessment appointment.

Select...YesNoPrefer not to say at this stage

Do you have any other caring responsibilities (e.g., for other children, elderly relatives etc.)
Select...YesNo

Incident(s) Information

Have they previously received support at Notts SVSS?
YesNo
Is the referral in relation to recent and/or non-recent experience(s)?*
Select...Recent (within the last year)Non-recentBoth
What is the referral in relation to? (choose all that apply): *

Childhood Sexual AbuseDomestic AbuseExploitationHarassmentRapeRitual/CultSexual AssaultStalkingOther

Please select which service(s) they would like to access?*

Further information regarding each service can be found under the “How We Can Help” tab on our webpage.

HelplineDrop inCounselling servicesCBTEMDREmail supportISVA serviceSurvivors support serviceSupport for friends, families and carersGroup supportMindfulnessCreating safetyTherapeutic support servicePeer supportSARC servicesTraining and talks
Has the incident(s) been reported to the Police?
Select...YesNoUnsure

What is the current status?
Select...Under InvestigationPolice No Further ActionOpen to CourtsCriminal Justice System process completedNot knownN/A
To your knowledge, is the client currently affected by ongoing domestic abuse and/or sexual violence?
YesNo

Preferences

Support format preference:
In-personOnlineTelephone

We can offer an additional service to help people feel more stable and resilient, this is provided by the organisation Mind and is available without a long wait. Do you want us to tell them more about this service?
Select...YesNoNot sure

Do you have a preferred gender of practitioner?
Select...FemaleMaleNo specific preference / either is fine

Is there any other information you would like to share with us?

Privacy

The client agrees to their data being processed in line with Notts SVSS privacy policy*:
Client agrees
The referrer agrees to their data being processed in line with Notts SVSS privacy policy*:
I agree
You can visit our Privacy Policy here

After you submit your form you will be taken to a thank you screen. If you do not see this or have difficulties with the form please contact our helpline on 0115 941 0440.