Agency Referral – Online – Devon Rape Crisis and Sexual Abuse Services

Agency / Referrer Details
Data Protection*
By ticking this box you are confirming that you have the service users explicit consent to make a referral to Devon Rape Crisis and Sexual Abuse Services and provide us with the service users name, contact details, reasons for referring, equality and diversity information.
- I confirm that I have the service users explicit consent to make a referral to Devon Rape Crisis and Sexual Abuse Services
Full Name of Referrer*
Job Title of Referrer*
Agency*
Referrer Telephone
Referrer Mobile*
Referrer E-Mail*
How did you hear about DRCSAS?

Service User Personal & Contact Details
First Name*
Last Name*
Date of Birth*
Date Format: DD slash MM slash YYYY
Address*
Street Address Address Line 2 City County Postal Code
Is it OK To Send Letters?
- No
- Yes
Home Telephone
Is It OK To Call or Leave a Message?
- OK To Call
- OK To Leave a Message
Mobile Telephone*
Is It OK To Call, Text or Leave a Message?*
- OK To Call
- OK To Text
- OK To Leave a Message
E-Mail Address
Is It OK To E-Mail?
- OK To E-Mail

Domestic Abuse
Is the service user currently, or have they recently (past 6 months) been at risk of domestic abuse?
- No
- Yes
DRCSAS are not domestic abuse specialists and the support we offer is specialised for survivors of sexual violence who are not at risk / haven’t experienced domestic abuse in the past six months.

SAFE / Fear-Less / Victim Support are specialists in offering support to people who have experienced, or are experiencing, domestic abuse and are far better placed to support you at this time.

Sexual Offence
Is the service user currently being investigated, or have they been convicted of, a sexual violence offence?
- No
- Yes
We do not offer support to anyone who has been charged or convicted of sexual offences or who is currently under investigation for such offences.

Background
Brief overview of incident / why you’re seeking support at this time - we do not need you to go into great detail.*
When the incident took place and how long for*
Service User's relationship to perpetrator (e.g. male family member, female partner etc.)*
Is there any contact with the perpetrator/s now?*

Support
Are there any concerns about the service user's safety / risk of harm / safeguarding?*
Is the service user currently receiving / waiting for support from any other service?*
Does the service user have any individual needs regarding an initial assessment (e.g. location, days/times, language, mobility, disability access etc.)*
How have you left it with the service user – what is the service user expecting?*

Agency / Referrer Details