Referrals

Please indicate support service required(Required)

Adult counselling (21 yrs+)

Children or Young Persons counselling (13-21 yrs)

Play therapy for children (4-13)

ISVA (18 yrs+)

CHISVA (under 18’s)

Parenting support

Support groups

We can offer a gender only space

Women only

Men only

I don't need either

Client Information

Name

First Last

Client Address

Client must live in the Thames Valley area

Postcode

Client must live in the Thames Valley area

Client's Home Tel No

Client's Mobile Tel No

Email Address

What is the preferred contact method?

Age(Required)

DOB(Required)

Gender/Pronouns

Ethnic Origin

Client availability for counselling(Required)

Please state your availability and preference for weekday and time slot Monday - Friday, AM (9.30am or 10.45am), PM (12.00pm, 1.30pm, 2.45pm or 4.00pm) or late PM (5.15pm or 6.30pm). Please note that there may be a longer waiting time if you require online, evenings or are only able to offer us limited availability. We do not offer sessions on weekends. If you would like access ISVA / ChISVA / parent / group support or play therapy, please put N/A.

Gender preference for counsellor

Female

Male

No preference

Please indicate if you would prefer face-to-face counselling or online sessions

Face-to-face

Online

Third Party Referrals / Referrals by professionals

If you are submitting this referral on behalf of a client, please complete the below sections. If this is a self-referral, please add N/A

Referral Agency Contact Name(Required)

Referral Agency Contact Email Address(Required)

Referral Agency Contact Telephone Number(Required)

Referral Agency Name (organisation)(Required)

Crime Number

Please complete if known

Log Number

Date(s) of Crime

Please complete if known

Date Crime reported to Police

Please complete if known

OIC's name and contact details

Please complete if known

Police Area

Please complete if known

How did you/person being referred hear about THR?(Required)

If client is under the age of 21, please confirm their legal status (Child in Care / Adopted or SGO / CP Plan/CIN Plan)(Required)

Please add N/A if not relevant

Name of social worker and team (where relevant)

Purpose of referral(Required)

Please give details and if known include brief details of offence/assault including dates or age when offences took place

Parent/Carer/Next of Kin Information

Parent/Carer/Next of Kin Name(Required)

First Last

Parent/Carer/Next of Kin Address (if different to client)

Parent/Carer/Next of Kin Contact Number(Required)

Parent/Carer/Next of Kin Email Address

Who should be contacted?

Client

Parent/Carer

Details of sexual harm

Was the alleged perpetrator a relative / known to the client? Please give as much information as possible.

What are the child / young person’s current difficulties?

Is the child / young person subject to a Child Protection or Child in Need plan or a Child Looked After?(Required)

Name of allocated social worker and contact details

Are there any safeguarding issues concerning the client or their dependants?

Please give details

GP details(Required)

Other professionals involved(Required)

Details of offence/assault

Type of Offence as defined by Sexual Offences Act 2003

Rape

Assault By Penetration

Other Sexual Assault

Location of Offence

Perpetrator's Home

Client's Home

Entertainment Venue

Outdoors

Public Buildings

Transportation

Client's Workplace

Other (i.e. friend's home / relative's home)

More than one of the above

Were prescribed drugs taken (voluntarily by client) prior to the assault?

Yes

Not known

Was alcohol consumed (voluntarily by client) prior to the assault?

Yes

Not known

Were recreational drugs taken (voluntarily by client) prior to the assault?

Yes

Not known

Suspected Drug Assisted Sexual Offence?

Yes

Not known

Perpetrator information

Perpetrator's Relationship to Victim

Partner

Ex-Partner

Relative

Acquaintance

Sex worker related

Stranger

Person in position of authority i.e. teacher / sports coach

Other

More than one of the above

Perpetrator Age Range

Number of perpetrators

Client Information

Third Party Referrals / Referrals by professionals

Parent/Carer/Next of Kin Information

Details of offence/assault

Perpetrator information

Services

Resources