Before you refer
  • If you are making a referral for someone who has been assaulted within the last 7 days and it is outside of office hours and/or a forensic and health consultation may be of benefit, please contact the nearest Sexual Assault Referral Centre.

  • If the person you are referring has any other safeguarding needs, please ensure that appropriate action is taken prior to referral.

Information submitted on this referral form will be treated as confidential and stored securely on the HERSANA data management system. Information is only shared with third parties with the explicit consent of the person being referred or if there is a risk of significant harm or safeguarding concerns.

Client Ethnicity







We only support people of Black African, Caribbean and Mixed heritage who self-identify as women, girls and femmes.

Our team understands that the journey to safety and healing is unique to each individual, and we are dedicated to connecting you with the appropriate services tailored to your situation. These services include:




  • Immediate Crisis Support: Access to emergency shelters, safety planning, and crisis counselling.


  • Long-Term Assistance: Signposting to organisations specializing in legal aid, mental health support, housing, and more.


  • Culturally Sensitive Services: If you require support that addresses your specific cultural background or needs, we can help connect you to relevant resources.


If you or someone you know needs assistance, please visit our support groups and advice page or reach out using the contact information below, and our team will guide you through the next steps


You are not alone, and help is available.

Your Information
Please select the organisation which best describes you









Client Information
Which of the following are safe forms of communication?



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Immigration Status





















Interpreter Required


Marital Status











Do they have any dependents?


Gender


Gender


Gender


Gender Identity








Sexuality










Religion

























Employment Status



















Accommodation






























Gender-based Violence Select all that are relevant




















Issues Select all that are relevant








































































Risks Select all that are relevant





















































Disabilities Select all that are relevant















Include information on: - safeguarding or risk issues. - additional information on the criminal justice process (see below) if relevant. - information on the types of the support the client particularly wishes to access, if known. - type of offence.
Are you aware if the client has previously used our services?



Was this reported to the police?


(if known)
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Police Force











































Open to Court


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