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

Ethnicity other

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

Organisation type other

Organisation Name

Your Name

Your Phone Number

Your Email Address

Client Information

Client's First Name

Client Last Name

Client's Address Line 1

Client's Address Line 2

City/Town

County

Postcode

Client's Email Address

Client's Phone Number

Which of the following are safe forms of communication?

Phone
Text
Email

Alternative Safe Contact Details

Date of Birth

Age at Time of Incident

Nationality

Primary Language

Interpreter Required

Yes
No

Do they have any dependents?

Yes
No

Name of Child

Gender

Female
Male

Date of Birth

Name of Child

Gender

Female
Male

Date of Birth

Name of Child

Gender

Female
Male

Date of Birth

Gender Identity

Woman (including Trans woman)
Man (including Trans man)
Non-binary
Intersex
Unsure/Questioning
Genderqueer/Fluid
Prefer not to say
Other

Gender Identity Other

Sexuality Other

Religion Other

Employment Status Other

Accommodation Other

Gender-based Violence Other

Issues Other

Risks Other

Disabilities Other

Please provide details of any other organisations or workers involved

Please provide a brief explanation for the reason for this referral

Are you aware if the client has previously used our services?

Yes
No
N/A

Was this reported to the police?

Yes
No

Crime Ref No

Date of Assault

Date Reported

Police Force Other

Police Force Detail

Police Investigating Officer

Alleged Perpetrator Age

Alleged Perpetrator Relationship

Open to Court

Yes
No

Court Start Date