Online Self Referral Form

Your Details

How should we contact you?

Permission to leave a phone message*:
YesNo

Are we allowed to leave a message on call-screening services on your phone? *:
YesNo
Permission to write*:
YesNo
Permission to send text*:
YesNo
Permission to contact via Email*:
YesNo

Preferred contact method*:
PhoneEmailLetter
Best time to call (Please note that calls from our service show as a “Private number”)
AMPMEvening
Please tell us if there are any restrictions contacting you.

Please provide your GP's Contact Details*

GP details are required for safeguarding purposes to access our support. We will be sending a letter to your GP to inform them that you are accessing our service.

GP Address & Postcode*
GP Telephone Number

About You

Are you involved with other voluntary/statutory agencies?
YesNo

Are you at any risk from abuse now?*
YesNo

Do you have any disabilities?

Learning DifficultiesNeurodivergencePhysical DifficultiesMobility IssuesMental Health DifficultiesHearing impairmentSight impairmentCognitive impairmentLong-term Health ConditionsNoneOther
Do you have any additional requirements?Select...Sign LanguageHearing LoopWheelchair AccessMedical ConditionGuide or Support DogOther requirements (i.e., ground floor access)

What is your gender?Select...MaleFemaleNon-binaryPrefer not to sayOther (Please state)

Is the gender you stated the same as the one you were assigned at birth?Select...YesNoPrefer not to say
What are your pronouns?Select...She/herHe/himThey/themPrefer not to sayOther (Please state)

How would you describe your sexuality?Select...Heterosexual/ StraightBisexualLesbianGayPansexualAsexualPrefer not to sayOther (Please state)

What is your ethnicity?Select...White EnglishWhite WelshWhite ScottishWhite Northern IrishWhite IrishGypsy or TravellerAny other White backgroundWhite and Black CaribbeanWhite and Black AfricanWhite and AsianAny other Mixed or Multiple backgroundsAsian BangladeshiAsian IndianAsian PakistaniAsian ChineseAny other Asian backgroundBlack AfricanBlack or Black BritishBlack CaribbeanAny other Black backgroundAny other Ethic groupPrefer not to sayOther

Do you have any religious beliefs?Select...BuddhistCatholicChristianHinduIslam/MuslimJudaism/JewishSikhNo ReligionPrefer not to sayOther (please state)

What is your Immigration Status?Select...Asylum SeekerDiscretionary LeaveDomestic Violence Indefinite Leave to Remain (DVILR)EEA National HolidayHumanitarian ProtectIndefinite leave to remainMigrant Victims of Domestic Abuse Concession (MVDAC)Pre-settled statusRefugeeSettled StatusSpousal VisaStudy VisaUK NationalUnaccompanied MinorWork VisaPrefer not to sayOther

Do you have any immigration-related issues that affect your access to services?
Do you require an interpreter?
YesNo

What is your 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

Accommodation

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

Are you currently pregnant or have you had a baby in the last 12 months? Select...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 you previously received support at Notts SVSS?YesNo
Are you contacting us in relation to a recent and/or non-recent experience(s)?Select...Recent (within the last year)Non-recentBoth
Is the referral in relation to (choose all that apply):

Childhood Sexual AbuseDomestic AbuseExploitationHarassmentRapeRitual/CultSexual AssaultStalkingOther

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

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

Select...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

Current status Select...Under InvestigationPolice No Further ActionOpen to CourtsCriminal Justice System process completedNot knownN/A

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 you 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?

Consent

Please tick the box below to show consent given for referral to Notts SVSS for support and agreement to Notts SVSS Privacy Policy

I agree to the above

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.