Professional referral form

Professional Referral - Adult Services (18+)

This form should be used where an individual wishes to access therapeutic or wellbeing support. If an individual has, or is considering, reporting their experience to the police, the referral should be made on the ISVA referral form.

Client consent

Client Details

Client Date of Birth(Required)
Client Address(Required)
Communication Preferences(Required)
It is important that we are able to make direct contact with the referred client, please let us know how they are happy for us to communicate with them. Please note that calls from us tend to be on a withheld number and letters on headed paper.
Please tell us anything you think we need to know when making contact with the client i.e. they require an interpreter, large text or a request that we call at a certain time of day

Referrer Details

Please let us know what support you have, or are, providing to the client you are referring.

Support Needs

Here you can tell us about the client's experience of sexual harm, i.e. when it occurred, whether it was an isolated incident or pattern of abuse and their relationship with the perpetrator.
It's important for us to know how the experience is impacting on the individual's daily life now, i.e. how their mental health is affected, whether they are using alcohol or drugs. Is the client currently accessing any support, if so, from whom?
Convictions(Required)
Does the client have any recent convictions for violent or sexual offences?

Monitoring Information

It is important to us that our services are available to everyone. In order for us to monitor this, it would help if you would provide us with the following information about the person you are referring. We share this information with our funders as anonymous data.
Disability