RASASC Guildford

Rape and Sexual Abuse Support Centre (RASASC)

Family Support Service referral form

RASASC's Family Support Service is aimed at families and carers of survivors.

Your details

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Details of the person being referred for Family Support

First name:

Surname:

Email:

Address and postcode:

phone number:

How did you hear about us?

Relationship to the survivor:

Best way to contact?

Is it ok to leave a voicemail?

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Details of the survivor

Their first name:

Their surname:

Their date of birth:

Their gender:

Are they being supported by RASASC?

yes

If you're able to, please give a brief description of why you are seeking help from our Family Support service:

If we have a late cancellation (within 24 hours or less) for a family support assessment, would you be available to attend?

Yes

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If you are referring from an agency, please add your details here *Please note: We will be able to confirm receipt of a referral, but we cannot give any other information to referring agencies without the client's consent. As the agency, you are responsible for the safeguarding needs of your client.*

Do you have the client’s consent to make a referral on their behalf?

Yes

Name of agency:

Agency contact person:

Agency address and postcode:

Agency contact number:

Contact email:

Relationship to the survivor:

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In order for RASASC to meet the aims and commitments set out in its equality policy, including not discriminating under the Equality Act 2010, we need to build an accurate picture of who we support in order to encourage equality and diversity. The anonymised data is also required by our funders, and improves our ability to apply for funding. We need your help to enable us to do this, and we’d be grateful if you could complete the following questions:

Do you identify with the gender you were assigned at birth?

Age

Ethnicity

Sexual orientation

Religion or belief

Do you consider yourself to have a disability or health condition?

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Please read our Privacy Policy to understand how we use your data

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I confirm that I have read and understood the RASASC Guildford Privacy Policy, and I consent to you using my data

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We support survivors of all genders over the age of 13 from across Surrey, who have been raped, sexually abused or have had an unwanted sexual experience.

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