Professional Referral Form

You can refer someone you're working with by filling in the referral form below.

Professional Referral Form

If you're looking for support for yourself, please use the self-referral form

Professional Referral Form

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
• Women, children and those from the LGBTQ+ Community
• People who have been impacted by some form of domestic violence or abuse in their lives

Sexual Abuse and Violence


I have assessed this person to be at:
Would you like a copy of this referral sent to the above address?
Client Information
Date of Birth
Client Address
Is it safe to: *
Preferred contact method (tick all that apply):
Client has children under 18?
Client GP Address

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



Sexual Orientation


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

Referral Details

Please tell us the reason for this referral

Required Services: *