SAASSBMK

Referr someone to SAASSBMK/SAM Project

Thank you for contacting us.
We provide support to anyone whose life has been affected by sexual assault and abuse over the age of 16. The SAM Project is part of SAASSBMK and all referrals are handled by the same team.
Please complete this form with as much information as possible. If there is a question you feel uncomfortable answering here and would prefer to discuss in person, feel free to leave it blank. If you need support to complete this form, please contact us on 01296 719772 or email support@saassbmk.org.uk or support@samproject.org.uk.
The information you give will be treated with respect and care and will not be shared with a third party without the individual's explicit consent in line with the principles of the Data Protection Act 2018. Please see our privacy policy for more information. You can remove your consent at any time by contacting support@saassbmk.org.uk or support@samproject.org.uk or calling 01296 719772.
You must have the consent of the survivor to make a referral to any of our services on their behalf. Please do not refer anyone unless they have given their explicit consent.

Person making the Referral

If you are a professional making the referral please give your Organisation Name

Your Name *

Your Contact Telephone or mobile number*

Your Email*

About the person you want to refer

First Name *

Last Name *

Phone Number

Email

Preferred contact method (if known) * Please tell us if there are any restrictions about contacting them in the information box at the end of the form.

Preferred pronouns (if known) *

Date of Birth *

Address line 1

Address line 2

Address line 3

Town/City

Postcode *

Which is the closest location to them to access services? *

If possible, please provide emergency contact name, relationship to them and telephone number

More about the person you want to refer

If known, please answer the following questions. If you don't know leave it blank.

Their Gender

Is their gender the one that was assigned to them at birth?

Their Sexual Orientation

Their Ethnicity

Their Religion

Do they have a diagnosed disability and/or additional needs?

Please provide their GP Practice name and phone number

Have they previously received support at SAASSBMK?

Is the referral in relation to a recent and/or non-recent experience(s)?

Reason For Referral

Is the referral in relation to (choose all that apply):

Childhood Sexual Abuse

Domestic Abuse

Exploitation

Harassment

Rape

Ritual/Cult

Sexual Assault

Stalking

Other

Please would you give us a brief outline of what the person you are referring would like support with? *

Has this been reported to the police?

If the case is active, what is the name of the Police Force, Officer in charge and contact details?

Where did you hear about us?

Do they have any additional needs that may require support for them to access our services?

If known, please provide the name, job title, name of organisation and contact details of any other professional working with this person (e.g. support worker, mental health professional, etc). Or any other information you want to share with us.

Consent

I confirm that the person I am referring has given their permission for this referral to be made and for SAASSBMK to make direct contact with them. By confirming this, I also confirm that the person I am referring has given their permission for SAASSBMK to store their data confidentially and has agreed to SAASSBMK’s privacy policy.

I agree to the above

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