LGBT Therapy Professional Referrals

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LGBT Therapy Professional Referrals

This form is for professionals to refer those from the LGBT community who have experienced domestic abuse to Rise for Therapy.

Please complete the referral form below and we will contact the survivor to assess what we can do to support them.

If you think that the person you are referring is in immediate danger, please call the police on 999.

LGBT Therapy Professional Referrals

LGBT Therapy Professional Referral Form

RISE LGBT Therapy Service offers support to:

• People who live in Brighton and Hove
• All members of the LGBT Community
• People who have been impacted by some form of domestic violence or abuse in their lives
• People who consent to being contacted by us to discuss their support options in relation to their experience of domestic violence and abuse specifically
• People who are not currently in crisis or at risk

Safeguarding

I have assessed this person to be at:
GDPR and Consent
Would you like a copy of this referral sent to the above address?
Date of Birth
Client Address
Is it safe to: *
Preferred contact method (tick all that apply):
Does client have children under 18? *
Does client have any other dependents? *

To help us meet your client's needs, please give us some more details about them

Disabilities

Does your client have any of the following disabilities? (Tick all that apply)

Does your client have any of the following accessibility requirements?

Tick all relevant boxes

Mental Health History and Diagnoses

Is your client okay communicating in English?
Does your client need an interpreter?

Your clients ethnicity

Please give us more information