Secure online referral SARC Referral Form Step 1 of 8 - Details of Referrer 0% Terms & Conditions*I confirm that I have obtained written or verbal consent from the person being referred. They are aware that in order for the best care and support to be provided to them, this referral will result in information about them being shared with: Devon and Cornwall Sexual Assault Referral Centres (SARC) managed by Royal Devon University Healthcare NHS Foundation Trust, Local Therapy services including The Children’s Society and Devon Rape Crisis and Sexual Abuse Services, and The Independent Sexual Violence Advisor services provided by The Bridge Partnership. If this referral is regarding a child, information may also be shared with child protection teams local to the child. They understand that services that might be offered as a consequence of this referral include a forensic medical examination, ISVA support, counselling and other therapeutic services. I accept the above Terms & Conditions 1. Details of ReferrerServices requested Non-recent medical assessment (to arrange an acute medical assessment please call us on 0300 3034626) ISVA Therapy Please note, by requesting an ISVA referral you are consenting to information being shared with the Bridge Project and/or The Children’s Society who provide the ISVA service.Date of Referral* DD slash MM slash YYYY Name of person making referral*Agency and Role*Phone Number / Fax Number*Email Address* Enter Email Confirm Email Address Street Address Address Line 2 Town/City County Postcode Crime Reference/Log Number*If you don’t have one, please input N/ADate of Forensic Medical Examination (if applicable) DD slash MM slash YYYY Police ABE interview status* Interview taken place To be arranged N/A Date of police ABE interview DD slash MM slash YYYY Has this been reported to the Police?* Yes No OIC Name and Contact DetailsFor Children and Young People under 18 years, has there been a strategy discussion? Yes No Why hasn't there been a strategy discussion?Name of relevant health representative at strategy discussion 2. Details of Person to be ReferredName*AgeDate of Birth* DD slash MM slash YYYY Gender Male Female Transgender other Safe Contact Telephone Number (landline and/or mobile)*Safe email address Safe Address and Postcode*Preferred method of contact Landline Mobile email letter Is it safe to leave a message Yes No GP Name, Address & Telephone NumberGP NameGP Telephone NumberGP Address Street Address Address Line 2 Town/City County Post Code Health Visitor/School Nurse Name, Address & Telephone NumberPaediatrician (if involved) Name, Address and Telephone NumberOther Professionals involved Names, Addresses & Telephone Numbers*Please include health visitor, school nurse, named social workers, mental health support workers etc as applicable Ethnicity White British White Irish White other Mixed White and Black Caribbean Mixed White and Black African Mixed White and Asian Any other mixed background Asian or Asian British Pakistani Asian or Asian British Bangladeshi Any other Asian background Black or Black British Caribbean Black or Black British African Any other Black background Chinese Any other ethnic group Religion Christian Buddhist Hindu Jewish Muslim Sikh None Other Sexual Orientation Heterosexual Gay / Lesbian Bisexual Other Unknown Relationship status of person being referred Married Civil Partnership Co-habiting Divorced Widow / widower Single Separated Other Caring responsibilities of person being referred* None Pregnant or Child under 6 months Child 6 months to 17 years Other caring responsibilities Learning Difficulties Yes No DetailsPhysical Disabilities Yes No DetailsAny diagnosed mental health problems* Yes No Any current or past suicidal ideation or attempts* Yes No Any current or past deliberate self-harm* Yes No DetailsDrugs and/or Alcohol Dependency Yes No DetailsRelated to CSE or at risk of CSE Yes No DetailsAre they able to communicate in English?* No difficulty Some difficulty no understanding of English Is an interpreter needed?* Yes No 3. Details of Adults (for children and young people referrals only)Name parent / carer 1Relationship Mother Father Foster Carer Step-parent Grandparent other Are they the main carer Yes No Do they have parental responsibility for the child / young person being referred Yes No Telephone numberAddress Street Address Address Line 2 Town/City County Post Code Ethnicity / first languageName of parent / carer 2 or other significant adultsRelationship Mother Father Foster Carer Step-parent Grandparent other Are they the main carer Yes No Do they have parental responsibility for the child / young person being referred Yes No Telephone numberAddress Street Address Address Line 2 Town/City County Post Code Ethnicity / first languageAre parents/carers aware of this referral? Yes No Have parents/carers consented to this referral? Yes No Has child/young person been made aware of this referral? Yes No Has child/young person consented to this referral? Yes No 4. Children of the household or other relevant childrenChild / Young Person 1Name of childDate of Birth DD slash MM slash YYYY Gender Male Female Transgender other Relationship with referred child / young person Child of referred person full brother or sister half-brother or sister step-brother or sister other Telephone numberAddress Same as child Street Address Address Line 2 Town/City County Post Code Ethnicity / first languageAdditional child / Young Person 1 Add another child / young person Name of childDate of Birth DD slash MM slash YYYY Gender Male Female Transgender other Relationship with referred child / young person Child of referred person full brother or sister half-brother or sister step-brother or sister other Telephone numberAddress Same as child Street Address Address Line 2 Town/City County Post Code Ethnicity / first languageAdditional child / Young Person 2 Add another child / young person Name of childDate of Birth DD slash MM slash YYYY Gender Male Female Transgender other Relationship with referred child / young person Child of referred person full brother or sister half-brother or sister step-brother or sister other Telephone numberAddress Same as child Street Address Address Line 2 Town/City County Post Code Ethnicity / first languageAdditional child / Young Person 3 Add another child / young person Name of childDate of Birth DD slash MM slash YYYY Gender Male Female Transgender other Relationship with referred child / young person Child of referred person full brother or sister half-brother or sister step-brother or sister other Telephone numberAddress Same as child Street Address Address Line 2 Town/City County Post Code Ethnicity / first languageAdditional child / Young Person 4 Add another child / young person Name of childDate of Birth DD slash MM slash YYYY Gender Male Female Transgender
