Young Person (13 – 17 Yrs)
Independent Sexual Violence Advisor Service Referral Form / /
Please completed all the boxes, remember you must obtain consent from the person you are referring.
Email completed form to: /
Contact detailsReferrer Name: / Email:
Referrer Agency: / Phone No:
Young Person (YP) personal details
First Name: / Surname:
Gender / D.O.B:
Address
(Inc. Postcode)
Safe to post?: / Yes ☐ No ☐
Preferred Contact No:
Has this number been seized? (provide alternative) / Yes ☐ No ☐
Other methods of contact:(email address)
Safe to: / Call ☐ Text ☐ Leave Message ☐ (Please tick all that apply)
Who does YP live with?
Are they aware?(supportive) / Yes ☐ No ☐
Statistical Information
Ethnicity:
Any other ethnic group ☐ / Arab ☐ / Asian Other ☐ / Bangladeshi ☐
Black African ☐ / Black Caribbean☐ / Black Other ☐ / Chinese ☐
Indian ☐ / Not Given ☐ / Not Known ☐ / Other Mixed ☐
Pakistani ☐ / White British ☐ / White Gypsy Irish Traveller ☐ / White Irish ☐
White Other ☐ / White & Asian ☐ / White & Black African ☐ / White & Black Caribbean ☐
Marital Status:
Single☐ / Married ☐ / Co-habiting ☐ / Divorced ☐ / Widowed ☐ / Civil law Partnership☐ / Unknown / Other ☐
Disability / Factors / Wellbeing: (Tick all that apply)
Physical Disability ☐ / History of Mental Health ☐ / History of Self Harm ☐ / Learning Disability ☐
Alcohol ☐ / Domestic Abuse ☐ / Drug Assisted ☐ / HBV/FGM ☐
Sex Worker ☐ / Substance Misuse ☐ / Risk of Suicide - level - Low☐ Med ☐High ☐
Give any further details:
Languages (If required)
Native Language
Level of English:
Fluent / / Conversational / / Read / / Written /
Native Language / Yes No
School / College
School / College attending
Are School /College aware of Incident(s) / Yes ☐ No ☐
Contact at School / College:
Incident & Perpetrator Details
Date of Incident: / Location of Incident:
Forensic medical taken place: / Yes ☐ No ☐ / Where?
Perpetrators Name:
Date of birth:
Relationship to Perpetrator:
Perpetrator’s Address
(Inc. Postcode):
Perpetrator’s current situation (arrested/bail conditions etc)
Where did the offence take place
Were there weapons involved? If so, please state
Police involvement(Please complete if police are investigating)
Reported to the Police: / Yes ☐ No ☐ / Supporting Police Action: / Yes ☐ No ☐
URN No. / Crime Ref No. / CSS No.
Bail date / Bail conditions:
Which Police Force: / Officer Name:
Officer contact no:
Officer email address:
Type of Offence: / Rape ☐ / Assault by Penetration ☐ / Other Sexual Assault ☐
Safeguarding & Other Information
CS referral made / CS already involved? / Yes ☐ / Social Worker details:
No ☐ / Why not:
Was there any concerns regarding to the YP (Behaviour / relationships / bullying / home environment) prior to the incidents / Yes ☐ No ☐ / Details:
Domestic Abuse cases - MARAC / DASH (over 16’s)
Has a DASH risk assessment been completed? / Yes ☐ No ☐ / If yes, please attach a copy.
What was the score?
Has a MARAC referral been completed? / Yes ☐ No ☐
Other Information
Do you know of any reason why it may not be safe for a YP ISVA to do alone home visit? (for example, violent behaviour, allegations against professionals, other people that have access to the address, alcohol/drug use, contagious conditions, etc) / Yes ☐ No ☐ / Give details:
Have you/other professionals visited the home? / Yes ☐ No ☐ / Give details:
Is there anything regarding the home environment that you feel it would be useful for a YP ISVA to be aware of prior to doing a home visit? / Yes ☐ No ☐ / Give details:
Other agencies involved with Young Person(add more lines if required)
Agency: / Name of worker: / Contact details:
Any Other Relevant Information
Young Persons views feelings
Is YP considering reporting / supporting police action? / Yes ☐ No ☐ / Details:
Is YP still in engaging with perpetrator? / Yes ☐ No ☐ / Details:
Does YP identify as a ‘Victim’? / Yes ☐ No ☐ / Details:
Consent for referral
Clients Consent – has the YP ISVA service been explained to the client and have they consented to this referral? / Yes ☐No ☐ / Date:
Please note that all referrals are subject to the discretion of the Service Manager.
SSC 002Review: Aug 18