Are you making this referral for you or someone else?
—Please choose an option—YourselfSomeone else *with their explicit consent

About person accessing service
First Name

Last Name

Pronouns
—Please choose an option—He/HimShe/HerThey/ThemOther
Are you over 18 years of age?
—Please choose an option—YesNo
Date of Birth

Address

Town/City

Post Code

Phone Number

Email

Preferred Initial Contact
PhoneSMSEmail
Is it safe to leave a message?
—Please choose an option—YesNo
Best time to make contact?

Are you able to communicate in English?
—Please choose an option—YesNo
Do you require an interpreter?
—Please choose an option—YesNo

About the Abuse

Type of Abuse
Sexual AbusePhysical AbuseNeglect or OmissionSpiritual AbuseConversion TherapyFinancial AbuseDomestic AbuseEmotional AbusePsychological AbuseModern SlaveryOrganisational AbuseDiscriminationOther

When did this abuse occur?
Within 24hrsWithin 72 HoursWithin 10 daysWithin 6 monthsWithin 12 monthsOver 12 months

In Which denomination did the abuse occur?
Church of EnglandChurch in WalesCatholic Church in England and Wales

In which Diocese did this occur (if known)?

Age at time of incident?
—Please choose an option—18 or overUnder 18

Name of Perpetrator (If Known)
Title

First Name

Last Name

Role of Primary Perpetrator
—Please choose an option—Church employeevolunteerparishionerspousefamilyotherunknown

Police/Church Investigations

Has the incident been reported to the police?
—Please choose an option—YesNo

Is a criminal Investigation ongoing?
—Please choose an option—YesNoUnknown

Has the incident/abuse been reported within the church, or to Diocesan safeguarding?
—Please choose an option—YesNo

If yes, which Diocese?

More about you

Gender?
—Please choose an option—MaleFemaleOther

Ethnic origin of person being referred
—Please choose an option—Not knownWhite BritishWhite IrishWhite OtherBlack BritishMixed White and Black backgroundMixed White and Black AfricanMixed White and Black CaribbeanMixed White and AsianAny other mixed backgroundAny other Asian backgroundBlack CaribbeanBlack African, IndianPakistan, BangladeshiChineseCaribbeanAfricanWhite gypsyIrish traveller

Religion
—Please choose an option—Roman CatholicChurch of EnglandChurch in WalesOtherChristianBuddhistHinduJewishMuslimSikhOtherAtheistAgnosticPrefer not to Say

Sexual Orientation
—Please choose an option—AsexualBisexualGayHeterosexualLesbianNot DefinedPansexualQuestioningPrefer not to sayother

Do you have a learning difficulty?
—Please choose an option—YesNoPrefer not to say

Do you have a physical disability?
—Please choose an option—YesNoPrefer not to say

Do you have any mental health issues?
—Please choose an option—YesNoPrefer not to say

Do you have any criminal convictions we should be aware of?
—Please choose an option—YesNo

If yes, please disclose here

Any other relevant information

If you are able, please describe the abuse you have experienced below, and provide us with any other relevant information you may have

Where did you hear about us?
—Please choose an option—Church employeeChurch SafeguardingFamily or FriendLeaflet or PosterProfessionalSearch Engine or Websitesocial mediaother

If making a referral for someone else, please provide your details below.
First Name

Last Name

Pronouns

How do you know the person being referred

Should we contact you before the person being referred?
YesNo

Email

Phone Number

What organisation are you referring from, if any?