Your Details

Full Name*

Agency/Organisation

Address*

Email*

Telephone Number*

Have you referred to us before?*
—Please choose an option—NoYes

Client Details

Full Name*

Date of Birth*

Age*

Address*

Email*

Telephone Number*

Gender Identity*

Sexual Orientation*

Ethnicity*
ArabAsian or Asian BritishBlack, Black British, Caribbean or AfricanMixed or multiple ethnic groupsWhite/CaucasianOther Ethnic Group
Other Fill in this box

Does the client consider themselves to have a disability? If yes, please provide details.

What languages does the client speak? (Please note primary language)

Marital Status
SingleMarried/Civil PartnershipLiving TogetherDivorcedSeparatedWidowed

Religion
No ReligionChristianBuddhistHinduJewishMuslimSikhOther Religion

Immigration Status

Is it safe to leave the client a voicemail, email or text message?*
Yes – EmailYes – VoicemailYes – Text MessageNo – Not Safe to Call

Referral Details

Can you tell us a bit more about why you are referring this individual*

Risk Factors or Safeguarding concerns that we should be aware of (if applicable)

Physical or Mental health conditions that we should be aware of (if applicable)

Other social/economic concerns we should be aware of (if applicable)

What services are the client interest in from us*
1:1 Caseworker SupportCounsellingYouth ServicesSocial and Support Groups

Please tell us a bit more about what this client requires from us or wishes to achieve with our help*

Please provide the names and contact details (including reference numbers) for any other agencies that are supporting this client

Any additional information file you wish to attach to this referral (Max 5MB)

Disclaimers

I confirm the client is aware of this referral
I confirm the client has given consent for Support U to contact them using the details in this form
I understand and accept that Support U is not a crisis service and is unable to assist with individuals in crisis.
I acknowledge that I have considered the services that Support U provides and these closely match the needs discussed with the referral individual

Support U provides this referral service, and its services to the end user in line with its terms and conditions of service. By submitting this form you are agreeing to the terms and conditions outlined, and confirm on behalf of your referral individual that they are aware of and acknowledge these terms and conditions.

Your Details

Full Name*

Agency/Organisation

Address*

Email*

Telephone Number*

Are you registered with us as a Third Party Referer?*
—Please choose an option—NoYes

Have you completed a DASH with the client? If so, please provide the risk level/number*
No DASH Completed1 – Standard Risk2 – Standard Risk3 – Standard Risk4 – Standard Risk5 – Standard Risk6 – Standard Risk7 – Standard Risk8 – Standard Risk9 – Standard Risk10 – Medium Risk11 – Medium Risk12 – Medium Risk13 – Medium Risk14+ – High Risk

Client Details

Full Name*

Date of Birth*

Age*

Address*

Email*

Telephone Number*

Gender Identity*
—Please choose an option—FemaleMaleTransgenderNon-Binary/ConformingAgenderGender NeutralGenderqueerGenderfluidIntersexNone of the above

Sexual Orientation*
—Please choose an option—LesbianGayBisexualAsexualPansexualQueerQuestioningHeterosexualNone of the above

Ethnicity*
ArabAsian or Asian BritishBlack, Black British, Caribbean or AfricanMixed or multiple ethnic groupsWhite/CaucasianOther Ethnic Group

Does the client consider themselves to have a disability? If yes, please provide details.

What languages does the client speak? (Please note primary language)

Marital Status
—Please choose an option—SingleMarried/Civil PartnershipLiving TogetherDivorcedSeparatedWidowed

Religion
—Please choose an option—No ReligionChristianBuddhistHinduJewishMuslimSikhOther Religion

Immigration Status

Is the client pregnant?*
—Please choose an option—NoYesNot Applicable

Is the client in employment?*
—Please choose an option—NoYes

Does the client live with the perpetrator(s)?*
—Please choose an option—NoYes

Does the perpetrator(s) have access to the clients telephone/email?*
—Please choose an option—NoYes

Is it safe to leave the client a voicemail, email or text message?*
Yes – EmailYes – VoicemailYes – Text MessageNo – Not Safe to Message

Current Housing Situation

Please advise on the client’s current housing situation

Is the client looking for housing support in relation to the abuse?
—Please choose an option—NoYesNot Applicable

Referral Details

Can you tell us a bit more about why you are referring this individual*

Risk Factors or Safeguarding concerns that we should be aware of (if applicable)

Please provide the names and contact details (including reference numbers) for any other agencies that are supporting this client

Sexual Violence/Abuse

Please complete this section if this referral relates to a Sexual Violence or Sexual Abuse concern

Type of offence defined by the Sexual Offences Act 2003 (SOA 2203)
—Please choose an option—RapeAssault by penetrationOther Sexual Assault

Location of Offence
Client's HomePerpetrator's HomeEntertainment Venue/Night Time EconomyOutdoorsPublic/Civic BuildingTransportationClients WorkplaceOther

Was the assault assisted by substances/alcohol (non-voluntarily)?
—Please choose an option—NoYes

Was the client (voluntarily) under the influence of substances and/or alcohol prior to the assault?
—Please choose an option—NoYes

Perpetrator Information

Is the perpetrator’s identity known?*
—Please choose an option—NoYes

Please select the perpetrator type if known
PartnerEx-PartnerRelativeAcquaintance/FriendWork ColleagueClientStranger/Unknown

Estimated Perpertrator Age*

Reporting/Police

Has violence/abuse been reported to the police? *
—Please choose an option—NoYes

Crime Number (where applicable)

Log Number (where applicable)

Date reported

Any additional information file you wish to attach to this referral (Max 5MB)

Disclaimers

I confirm the client is aware of this referral
I confirm the client has given consent for Support U to contact them using the details in this form
I understand and accept that Support U is not a crisis service and is unable to assist with individuals in crisis.
I acknowledge that I have considered the services that Support U provides and these closely match the needs discussed with the referral individual

Support U provides this referral service, and its services to the end user in line with its terms and conditions of service. By submitting this form you are agreeing to the terms and conditions outlined, and confirm on behalf of your referral individual that they are aware of and acknowledge these terms and conditions.