South Yorkshire Independent Sexual Violence Service

This form is for individuals and professionals wishing to a make a referral for support from an Independent Sexual Violence Advisor (ISVA)

Personal Information

Full name ^*

Date of birth ^*

Address ^*

Postcode ^*

Telephone number ^*

Authorised methods of contact

Please check the methods we can use to make contact.^*

Telephone Text Voicemail Email Letter (All correspondence is issued in unmarked plain envelopes)

If an interpreter is required please enter the language

Risk Information

Are there any known risks relating to the client? ^*

If 'yes', please give details.

Is there a current risk relating to domestic abuse? ^*

If Yes, has a referral been made to a domestic abuse service? Please provide details.

Referrer Details ^*

Please check if you are making this request for support for yourself Please check if you are making this request for a child, family member or friend Please check if you are a professional making this request for support for someone

Professional Referral Details

Name

Organisation

Phone

Is the person aware that you are making this referral?

South Yorkshire Police Referrals ONLY

We are unable to accept referrals where explicit consent has not been given.

Please tick this box to confirm that the client has given explicit consent, as per the Victims’ Code.

Child or Young Person Referrals Only

If this referral is for a child or young person under 16, please provide the name of the safest contact- Parent / carer or guardian for us to contact in the first instance.

Name

Relationship

Contact number

Parent/guardian email

Is this person aware of the referral?

(Please check this box if the child or young person is over 16, wishes to access support independently and does not wish to provide details of an adult)

Incident Details

Please tell us the reason for referral (offence, date(s), relationship to suspect)
We know this can be very difficult so please only share what you feel comfortable with.

Name of suspect

If reported to the police please tell us Police Officer in Charge (OIC)

Crime Reference number (if known)

Please tick this box if the incident is in relation to Operation Stovewood

Please list any other agencies who are currently involved in support with the name of the lead worker

Monitoring Information

To complete the referral process, we need to collect some basic monitoring information. This helps us improve our services and is a requirement of our funders.

The details provided will be reported anonymously.

Ethnic group or background^*

Gender^*

Do you have any special needs we need to be aware of?

Data Protection

The data provided on this form is used to identify clients and assist the ISVA worker when contacting agencies as part of their advocacy role. This data on this form is treated as both 'personal' and 'sensitive' and subject to the policies of the local ISVA service provider with respect to confidentiality and data protection.

SRASAC acts as a 'data processor' on behalf of BSARCS, ROTHACS and DRASACS in order to refer clients into the appropriate local ISVA service provider. BSARCS, ROTHACS, SRASAC and DRASACS act as 'data controllers' for ISVA clients within their local area.