Professional Referral Form

Referrer Details

You can use the form below to refer people that you are working with for support with their experience of domestic abuse. RISE offers support to:

• People who live in Brighton and Hove

I confirm that the person being referred lives in Brighton and Hove

• Women, children and those from the LGBTQ+ Community

I confirm that the person being referred is a woman or member of the LGBTQ+ Community (To refer children, please use our CYP Referral Form)

• People who have been impacted by some form of domestic violence or abuse in their lives

I confirm that the person being referred has been impacted by Domestic Abuse

• People who consent to being contacted by us to discuss their support options in relation to their experience of domestic violence and abuse specifically

I confirm that the person being referred has consented to us contacting them about their experience of domestic abuse

Sexual Abuse and Violence

If the person you are referring has recently experienced or is currently experiencing sexual violence or abuse, please also refer to Survivors’ Network.

I have made a referral to Survivors’ Network for this person

Safeguarding

I have assessed this person to be at:

High risk (NB high risk cases should be referred directly to MARAC and Victim Support, not RISE)

Medium risk

Standard risk

I confirm that the required action has been taken for all other safeguarding needs before making this referral (see DASH, MARAC, and Victim Support for more information).

GDPR and Consent

All information is confidential and stored securely on the RISE servers. 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/safeguarding concerns *

I confirm that I understand what will happen to the information shared below, and that the person being referred has consented to this referral.

Referring Organisation Details: *

Person making referral: *

Relationship to the person you are referring:

Referrers Tel No: *

Referrers Email Address *

Would you like a copy of this referral sent to the above address?

Yes

Client Information

I confirm that the individual below has consented to this referral

Client First Name *

Client Last Name *

Date of Birth

Day

Month

Year

Client Address

Address 1 *

Address 2

Town/City

Post Code

County

Client Contact Number *

Client Email

Is it safe to: *

Yes, it's safe to call

Yes, it's safe to leave a voicemail

Yes, it's safe to send a text

Yes, it's safe to contact via email

Yes, it's safe to send post

Is there a safe time to contact?

Preferred contact method (tick all that apply):

Prefers Phone calls

Prefers Email messages

Prefers Text messages

Is happy with any contact method

Client has children under 18?

Yes

Client GP Address

Address 1 *

Address 2

Town/City *

Post Code *

County

Accessibility

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

Sex/Gender

Choose from the drop-down below:

If other, please specify:

Transgender

Yes

Pronouns

Sexual Orientation

Choose from the drop-down below:

If other, please specify

Disabilities

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

Physical disability

Learning disability

Hearing disability

Vision disability

Mental health disability

Long term condition

Speech impediment

Please give details:

Does your client have any of the following accessibility requirements?

Tick all relevant boxes

Help to get into or around buildings

Help with seeing or reading

Help with hearing

Help with comprehension

Other

Please describe:

Mental Health History and Diagnoses

Please tell us whether your client has a mental health diagnosis and/or if they are on any medication to help with mental health difficulties

Is your client okay communicating in English?

Yes

Does your client need an interpreter?

Yes

Which languages?

If not listed, please give details:

Your clients ethnicity

White

Black

Mixed race/Multi ethnic

Asian

If other, please describe:

Referral Details

Please tell us the reason for this referral

Details of the referral: *

Required Services: *

I am referring this person for ALL RISE Services