Skip to main content
Skip to footer
Safety exit
Hersana
Donate
Log in
Log in
Register
Expand Search
Our Services
Our services
Holistic Therapy
Live Chat
Our Partnerships
Independent Advocacy
Wholistic Outreach
Training
For Professionals
Support Us
About Us
News
Contact Us
Hersana
Menu
Our Services
Our services
Holistic Therapy
Live Chat
Our Partnerships
Independent Advocacy
Wholistic Outreach
Training
For Professionals
Support Us
About Us
News
Contact Us
Log in
Log in
Register
Expand Search
Donate
Agency Referral Form
Consent for storing submitted data
Yes, I give permission to store and process my data
Please select the organisation which best describes you
Agency
Business
Education
Funder
Media
Police
Religious groups
Third party
Other
Other
Organisation name
Your name
Your phone number
Your email address
Client first name
Client last name
Client Address line 1
Client Address line 2
Town
County
Postcode
Client telephone number
Client email address
Which of the following are safe forms of communication?
Select all that apply
Voicemail
Text
Email
Post
Alternative safe contact details
Date of birth
DD/MM/YYYY
Age at time of incident
GP
Client ethnicity
Asian or Asian British
Black or Black British
Chinese
Mixed or Dual
White
Prefer not to say
Other
Ethnicity other
Nationality
Immigration status
Asylum seeker
Discretionary leave
EEA national
Holiday
Humanitarian project
Indefinite leave
Leave to remain
No status
Prefer not to say
Pre-settled status
Refugee
Settled status
Spousal sponsor
Study Visa
UK national
Unaccompanied Minor
Undisclosed
Work visa
Primary language
Interpreter required
Yes
No
Marital status
Civil partnership
Cohabitating
Divorced
In a relationship
Married
Prefer not to say
Separated
Single
Under 16
Undisclosed
Widow
No. of dependants
Gender identity
Woman (including Trans woman)
Man (including Trans man)
Non-binary
Intersex
Unsure/Questioning
Genderqueer/Fluid
Prefer not to say
Other
Gender identity other
Sexuality
Heterosexual
Bisexual
Gay
Lesbian
Queer
Asexual
Pansexual
Unsure/Questioning
Prefer not to say
Other
Sexuality other
Religion
Agnostic
Atheist
Bahai
Buddhist
Catholic
Christian
Cult
Hindu
Humanist
Jain
Jehovah
Jewish
Mormon
Muslim
None
Pagan
Prefer not to say
Quaker
Rastafarian
Sikh
Spiritualist
Undisclosed
Wiccan
Zoroastrian
Other
Religion other
Employment status
Apprentice
Carer
Employed
Home maker
Long term sick
NEET
No recourse
Prefer not to say
Registered disabled
Registered unemployed
Retired
Self employed
Student - full time
Student - part time
Student - postgraduate
Student - undergraduate
Undisclosed
Unemployed
Voluntary work
Other
Employment status other
Accommodation
B&B
Care home
Detention centre
Foster care
General hospital
HMO
Homeless
Homeowner
Hostel
Housing association
In care
Living with parents
Local authority
Mental health unit
Mobile home
Mother & baby unit
Prison
Private rent
Refugee accommodation
Residential
Service family accommodation (SFA)
Settled accommodation
Sheltered accommodation
Sofa surfing
Student accommodation
Supported housing
Temp accommodation
Tent
Undisclosed
With family
Other
Accommodation other
Gender-based violence
Breast ironing
Current CSA
Current domestic abuse
Current sexual violence
Female foeticide
Female infanticide
Forced termination of pregnancy
Forced marriage
Female genital mutilation/cutting
History of domestic abuse
History of sexual violence
History of CSA
Harassment
"Honour" based violence
Labia pulling
Modern slavery
Online & digital violence
Stalking
Sexual exploitation
Trafficking
Other
Gender-based violence other
Issues
Select all that are relevant
Access issues childcare
Access issues transport
Accommodation problems
Alcohol problems past
Alcohol problems present
Anxiety
Bullying
Care leaver
Caring responsibilities
Depression
Diagnosed - Addiction
Diagnosed - Alcohol use disorders
Diagnosed - Anxiety
Diagnosed - Attention deficit disorder
Diagnosed - Attention deficit hyperactivity disorder
Diagnosed - Autism
Diagnosed - Bi polar
Diagnosed - Body dysmorphic disorder
Diagnosed - Brain injury
Diagnosed - Delirium
Diagnosed - Dementia
Diagnosed - Depression
Diagnosed - Dissociative Identity Disorder
Diagnosed - Drug misuse
Diagnosed - Eating disorder
Diagnosed - Epilepsy
Diagnosed - Fibromyalgia
Diagnosed - OCD
Diagnosed - Personality disorder
Diagnosed - Psychosis
Diagnosed - PTSD
Diagnosed - Schizophrenia
Diagnosed - Self harm
Drug problems past
Drug problems present
Eating disorder
Financial difficulty
Gambling problems past
Gambling problems present
Hoarding
Homelessness
Maternity
Mental health past
Mental health present
Miscarriage
Missing adult
Missing child
Multiple mental health diagnosis
None
Parenting problems
Personality problems
Post trauma symptom
Pregnancy
Prescription medication
PTSD
Racism
Recent birth
Safeguarding issues
Safety issues
Self-harm past
Self-harm present
Single parent
Sleep problems
Suicidal attempt past
Suicidal thoughts past
Suicidal thoughts present
Termination of pregnancy
Other
Issues other
Risks
Select all that are relevant
High risk of abduction
High risk of CSA
High risk of CSE
High risk of deportation
High risk of DA
High risk of FGM/C
High risk of forced marriage
High risk of forced termination of pregnancy
High risk of HBV
High risk of mental illness
High risk of running away
High risk of self-harm
High risk of substance misuse
High risk of suicide
High risk of SV
High risk perpetrator
High risk MARAC
Immediate risk
Low risk
Low risk MARAC
Medium risk
Medium risk MARAC
No current risks
No risks
Other
Risks other
Disabilities
Select all that are relevant
Blind/Visual Impairment
Deaf/Hearing Impairment
Learning difficulty
Long term illness health condition
Mental health
Mobility physical
None
Physical disability
Prefer not to say
Social/Behavioural impairment
Speech impairment
Undisclosed
Other
Disabilities other
Please provide a brief explanation for the reason for this referral
Include information on: - safeguarding or risk issues. - additional information on the criminal justice process (see below) if relevant. - information on the types of the support the client particularly wishes to access, if known. - type of offence.
Are you aware if the client has previously used our services?
Yes
No
N/A
Crime Ref No
(if known)
Date of assault
DD/MM/YYYY
Date reported
DD/MM/YYYY
Was this reported to the police?
Yes
No
Police force
ACPO
An Garda Siochana
Avon and Somerset Constabulary
Bedfordshire Police
British Transport Police
Cambridgeshire Constabulary
Cheshire Constabulary
City of London Police
Civil Nuclear Constabulary
Cleveland Police
Cumbria Constabulary
Derbyshire Constabulary
Devon & Cornwall Police
Dorset Police
Durham Constabulary
Essex Police
Gloucestershire Constabulary
Greater Manchester Police
Hampshire Constabulary
Hertfordshire Constabulary
Humberside Police
Kent Police
Lancashire Constabulary
Leicestershire Police
Lincolnshire Police
Merseyside Police
Metropolitan Police Service
Norfolk Constabulary
North Yorkshire Police
Northamptonshire Police
Northumbria Police
Nottinghamshire Police
South Yorkshire Police
Staffordshire Police
Suffolk Constabulary
Surrey Police
Sussex Police
Thames Valley Police
Warwickshire Police
West Mercia Police
West Midlands Police
West Yorkshire Police
Wiltshire Police
Other
Police Force other
Police force detail
Police investigating officer
Alleged perpetrator age
Alleged perpetrator relationship
Open to court
Yes
No
Court start date
DD/MM/YYYY
Let’s stay in touch. Sign up for our newsletter…
Send us your email address to receive all of our latest news & updates.
Sign Up
Sign up for our newsletter
Send us your email address to receive all of our latest news & updates.
Email Address
*
*
Required
Chat now