Agency Referral Form

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.








Your Information









Client Information
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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.







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