STARS - Referral Form

About The Referrer

1 Your Name *

2 Your relationship to client *

3 Agency

4 Your address *

5 Email *

6 Phone Number *

7 Do you have the consent of the client to make this referral? *

Yes

About The Person You are Referring

8 First Name *

9 Last Name *

10 How does the client like to be addressed?

11 Address line 1 *

12 Address line 2

13 Address line 3

14 Town/City *

15 Postcode *

16 Safe to post to the this address? *

Yes

Contact

Only supply contact information that is safe for us to use. Please supply at least one contact method

17 Mobile Number *

Preferred contact method *

Yes

Safe to leave voice mail *

Yes

18 Phone Number *

Preferred contact method *

Yes

19 Email *

Preferred contact method *

Yes

Safe to email client? *

Yes

More Information

20 Date of Birth *

Age *

21What are the client’s preferred pronouns?

22 What best describes the clients’ ethnic group or background? *

23 What gender does the client identify as? *

24 Does the client have a trans history? *

25 What best describes their sexual orientation? *

26 GP name & surgery *

27 Tell us about any other agencies supporting the client? (What support, Who, How Often, Address/contact details) *

Support Needs

Please note that for our Counselling Services, people need to be at least 12 months free from using substances or alcohol abuse and at least 6 months since any previous attempts on their own life or incidents of self harm. This will enable them to get the most from their therapy. However our ISVA services are able to support people within those categories.

Mental Health Issues

Substance/Alcohol misuse

Self Harm Issues

Suicide Ideation

If ANY are non recent or current, please give details (when and for how long) or otherwise put in N/A. *

29 Please tell us specifically about any prescribed medication? (if none, please put in N/A) *

30Does the client have any additional needs? For example a physical disability or a learning or communication need *

31Is there a social worker allocated to the client?

Yes

32Are there any children under 18 years of age who live at the property?

Yes

In this next section we will ask you about the reasons they are seeking support on behalf of the client.

33 Please give a brief explanation of why they are seeking support from STARS Dorset *

34Has the offence been reported to the police? *

35 Please tell us the type of offence (you may tick all that apply)

Child sexual abuse (under 18 years of age at the time of offence)

Rape

Sexual assault by penetration

Sexual touching by penetration

Sexual assault

Other

Don't know

36 When did the offence take place? *

37 What location did the offence take place? *

38 Where did the offence take place? *

39 How was the perpetrator known to the client? *

40 What gender did the perpetrator present as? *

Safety

Please tell us about the clients safety:

41Is the perpetrator aware of where the client lives? *

Yes

42 Does the perpetrator still contact the client? *

Yes

43 Please tell us about any safety planning you or other agencies have implemented to safeguard the client or any children and vulnerable adults that may be at risk *

44Was the sexual trauma experienced within a domestically abusive relationship? Please supply DASH/MARAC/HRDA information where relevant *

45 Is the client currently working with any domestic abuse agency ? If so, please give details or put N/A. *

Professional / Agencies Online Referral Form

Please complete this form to refer someone to our service. Review our privacy policy here.

About The Referrer

About The Person You are Referring

Contact

More Information

Support Needs

Safety