One YMCA Bedfordshire ISVA Service Referral Form

We offer free and confidential practical and emotional support to both children and adults who have experienced rape or sexual abuse of any kind – whether recent or non-recent. Those referred do not have to be working with police to receive ISVA support. We accept referrals from all agencies and third parties where consent has been obtained. We also accept self-referrals from those who want to access support.

We aim to respond to your referral within 48 working hours. If you are in urgent need of help, please call the Police on 999, Mental Health Crisis NHS 111 (option2) or the Samaritans on 116 123.

Phone Number (Is the number safe?)

Please indicate the best time to call

Safe to contact by

PostTextPhone

(If referring a child please give parent/guardian details and indicate who should be called)

Preferred method of contact (please tick)

PhoneTextEmail

Preferred Pronouns

She/HerHe/HimThey/ThemPrefer no to say

DISCLOSURE / INCIDENT DETAILS

Location of incident

Date of incident

Please give brief details of the incident

Reported to the police?

YesNo

Reported to SARC?

YesNo

ABE completed

YesNo

CURRENT STAGE OF CRIMINAL JUSTICE PROCESS (under investigation, with CPS, charged, trial/sec 28 dates, awaiting sentencing,NFA, withdrawn etc.

NAME OF OIC (Officer in Charge):

CRIME REFERENCE NUMBER:

ANY BAIL CONDITIONS / ORDERS?

DETAILS OF PERSON WHO COMMITTED HARM - IF KNOWN

Is this person known to the person who experienced the sexual abuse

YesNo

Please give details

ANY OTHER RELEVANT INFORMATION

Other / Comments

Referrals cannot be accepted without the following being completed, thank you.

CONSENT AND DATA PROTECTION AGREEMENT

One YMCA takes data protection very seriously and is committed to protecting your privacy. (Please visit www.oneymca.org to view our Privacy Policy) We will process the personal information you provide in a manner which is compliant with all applicable data protection legal requirements.  Information provided will not be shared with any third parties without prior consent unless it is necessary for the safeguarding/protection of a child or vulnerable adult

By clicking ‘Yes’ under verbal consent rather than obtaining a signature the referrer is confirming that all necessary consent requirements in this referral have been explained to the parent/carer and understood. The referrer is also confirming that the full content of the referral has been communicated to the parents/carers concerned.