Plymouth Sexual Violence Counselling Service Step 1 of 8 - Who are you making a referral for? 0% Please select the Therapy service* Therapy for an adult 18 years plus Therapy for a Young Person aged 0-18 years Please click to confirm and acknowledge that Select All Parent/guardian’s permission is granted for the child to engage in therapy The parent/guardian will participate in the Assessment The parent/guardian will support the child’s regular attendance If parental support is not available, the referrer/social worker/school representative is required to support the above Are you making this referral* For you For someone else Referral for someone elseIf you are making the referral for someone else* I confirm that I have obtained written or verbal consent from the person I wish to refer which allows you to share information with First Light. The person is aware of this referral and has consented to the details contained within the referral form to be shared in accordance with the General Data Protection Regulation (GDPR), the Data Protection Act 2018 and other UK or EU data protection. Referrer's contact details Mr.Mrs.MissMs.Dr.Prof.Rev.Mx Prefix First Last Address Street Address Address Line 2 City County ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country LandlineMobile numberEmail Are you* Friend or relative Professional ProfessionAgency Contact details if different to aboveNature of contact with refereeAll further questions in this online referral relate to the person being referred, and should be answered on their behalf where known Making ContactName* Mr.Mrs.MissMs.Dr.Prof.Rev.Mx Prefix First Last Name you would like us to usePronouns He/him She/her They/them Date of Birth Address Address Line 1 Address Line 2 City County Post Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Mobile*LandlineEmail* Preferred contact method* Landline Mobile Email Letter Is it safe to leave a message?* Yes No How is it safe to contact you?* Landline Mobile Email Letter When is the best time to make contact? : Hours Minutes AM PM AM/PM Are you able to communicate in English?*No difficultySome difficultyNo understandingIs an interpreter required? Yes For under 18’s onlyAre you* Under 18 Over 18 By completing this form you are giving permission for First Light to share these details with the Devon & Cornwall Sexual Assault Centre Paediatric Service* I agree More infomation about this serviceName of parent/guardian if under 18 only Mr.Mrs.MissMs.Dr.Prof.Rev.Mx Prefix First Last Relationship to child or young person if under 18 onlyContact details of parent / guardian (if different from above) Address Line 1 Address Line 2 City County Post Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country MobileLandlineEmail About the abuse, assault or violenceTo enable us to provide the person with the appropriate support we require the following information:Type of abuse* Rape Sexual Assault by Penetration Childhood sexual abuse Child Sexual Exploitation Online sexual grooming Other sexual assault Time of incident* Within 24 hours Within 72 hours Within 10 days Within 6 months Over 6 months Over 12 months Age at time of incident* Under 18 18 or over Both About the person who committed the abuse, assault or violenceName, if known Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Are they known to you, and if so how? Aunt/ Uncle Carer Cousin Ex-Partner Family Member Father Foster Parent Friend Known Person/ Associate Mother Partner Sibling Son/ Daughter Step Child Step Parent Unknown Person/ Stranger Work Colleague Other Number of perpetrators*Unknown123456moreIs there a restraining order or injunction?* Yes No At the time of the offence were you intoxicated?* Yes - Alcohol Yes - Drugs Yes - Both No Unknown Was the perpetrator intoxicated at the time of the offence?* Yes - Alcohol Yes - Drugs Yes - Both No Unknown Was a weapon used* Yes No Further comments Police investigationHas the incident been reported to the police?* No Yes Date reported Has there been an investigation? Within last 12 months Longer Has there been a court case? Within last 12 months Longer No Is there a criminal investigation ongoing?*UnknownYesNo More About YouWe will use the information you provide to help us support you more effectively. We also use equality and diversity data to help us reach everyone affected by sexual violence.Gender* Male Female Other Other Gender fluid Genderqueer Intersex Non-binary Questioning Transgender Prefer not to say Gender at birth* Male Female Ethnic origin*Not knownWhite BritishWhite IrishWhite OtherMixed White and Black backgroundMixed White and Black AfricanMixed White and Black CaribbeanMixed White and AsianAny other mixed backgroundAny other Asian backgroundBlack CaribbeanBlack African, IndianPakistan, BangladeshiChineseCaribbeanAfricanWhite gypsyIrish travellerPrefer not to sayReligion*UnknownNoneChristianBuddistHinduJewishMuslimSikhOtherPrefer not to saySexual orientation* Asexual Bisexual Gay Heterosexual Lesbian Not defined Pansexual Questioning Prefer not to say Relationship status*UnknownMarriedCivil PartnershipCo-HabitingDivorcedWidow/WidowerSingleSeparatedOtherCaring responsibilities*UnknownNonePregnant / child under 6 monthsChild 6 months – 17 yearsOther caring responsibilitiesDo you have a learning difficulty?* Yes No Prefer not to say Please provide detailsDo you have a physical disability?* Yes No Prefer not to say Please provide detailsDo you have any mental health issues?* Yes No Please provide detailsAre you in contact with other professionals?* Yes No Prefer not to say Are you alcohol or drug dependent?* Yes No Prefer not to say Any other relevant informationAny other relevant information Where did you hear about usFamily / friendLeafletProfessionalSearch engine & websiteSocial mediaA First Light partner agency Plymouth Counselling Referral form (NEW) Step 1 of 8 - Who are you making a referral for? 0% Please select the Therapy service* Therapy for an adult 18 years plus Therapy for a Young Person aged 0-18 years Please click to confirm and acknowledge that Select All Parent/guardian’s permission is granted for the child to engage in therapy The parent/guardian will participate in the Assessment The parent/guardian will support the child’s regular attendance If parental support is not available, the referrer/social worker/school representative is required to support the above Are you making this referral* For you For someone else Referral for someone elseIf you are making the referral for someone else* I confirm that I have obtained written or verbal consent from the person I wish to refer which allows you to share information with First Light. The person is aware of this referral and has consented to the details contained within the referral form to be shared in accordance with the General Data Protection Regulation (GDPR), the Data Protection Act 2018 and other UK or EU data protection. Referrer's contact details Mr.Mrs.MissMs.Dr.Prof.Rev.Mx Prefix First Last Address Street Address Address Line 2 City County ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country LandlineMobile numberEmail Are you* Friend or relative Professional ProfessionAgency Contact details if different to aboveNature of contact with refereeAll further questions in this online referral relate to the person being referred, and should be answered on their behalf where known Making ContactName* Mr.Mrs.MissMs.Dr.Prof.Rev.Mx Prefix First Last Name you would like us to usePronouns He/him She/her They/them Date of Birth Address Address Line 1 Address Line 2 City County Post Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Mobile*LandlineEmail* Preferred contact method* Landline Mobile Email Letter Is it safe to leave a message?* Yes No How is it safe to contact you?* Landline Mobile Email Letter When is the best time to make contact? : Hours Minutes AM PM AM/PM Are you able to communicate in English?*No difficultySome difficultyNo understandingIs an interpreter required? Yes For under 18’s onlyAre you* Under 18 Over 18 By completing this form you are giving permission for First Light to share these details with the Devon & Cornwall Sexual Assault Centre Paediatric Service* I agree More infomation about this serviceName of parent/guardian if under 18 only Mr.Mrs.MissMs.Dr.Prof.Rev.Mx Prefix First Last Relationship to child or young person if under 18 onlyContact details of parent / guardian (if different from above) Address Line 1 Address Line 2 City County Post Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country MobileLandlineEmail About the abuse, assault or violenceTo enable us to provide the person with the appropriate support we require the following information:Type of abuse* Rape Sexual Assault by Penetration Childhood sexual abuse Child Sexual Exploitation Online sexual grooming Other sexual assault Time of incident* Within 24 hours Within 72 hours Within 10 days Within 6 months Over 6 months Over 12 months Age at time of incident* Under 18 18 or over Both About the person who committed the abuse, assault or violenceName, if known Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Are they known to you, and if so how? Aunt/ Uncle Carer Cousin Ex-Partner Family Member Father Foster Parent Friend Known Person/ Associate Mother Partner Sibling Son/ Daughter Step Child Step Parent Unknown Person/ Stranger Work Colleague Other Number of perpetrators*Unknown123456moreIs there a restraining order or injunction?* Yes No At the time of the offence were you intoxicated?* Yes - Alcohol Yes - Drugs Yes - Both No Unknown Was the perpetrator intoxicated at the time of the offence?* Yes - Alcohol Yes - Drugs Yes - Both No Unknown Was a weapon used* Yes No Further comments Police investigationHas the incident been reported to the police?* No Yes Date reported Has there been an investigation? Within last 12 months Longer Has there been a court case? Within last 12 months Longer No Is there a criminal investigation ongoing?*UnknownYesNo More About YouWe will use the information you provide to help us support you more effectively. We also use equality and diversity data to help us reach everyone affected by sexual violence.Gender* Male Female Other Other Gender fluid Genderqueer Intersex Non-binary Questioning Transgender Prefer not to say Gender at birth* Male Female Ethnic origin*Not knownWhite BritishWhite IrishWhite OtherMixed White and Black backgroundMixed White and Black AfricanMixed White and Black CaribbeanMixed White and AsianAny other mixed backgroundAny other Asian backgroundBlack CaribbeanBlack African, IndianPakistan, BangladeshiChineseCaribbeanAfricanWhite gypsyIrish travellerPrefer not to sayReligion*UnknownNoneChristianBuddistHinduJewishMuslimSikhOtherPrefer not to saySexual orientation* Asexual Bisexual Gay Heterosexual Lesbian Not defined Pansexual Questioning Prefer not to say Relationship status*UnknownMarriedCivil PartnershipCo-HabitingDivorcedWidow/WidowerSingleSeparatedOtherCaring responsibilities*UnknownNonePregnant / child under 6 monthsChild 6 months – 17 yearsOther caring responsibilitiesDo you have a learning difficulty?* Yes No Prefer not to say Please provide detailsDo you have a physical disability?* Yes No Prefer not to say Please provide detailsDo you have any mental health issues?* Yes No Please provide detailsAre you in contact with other professionals?* Yes No Prefer not to say Are you alcohol or drug dependent?* Yes No Prefer not to say Any other relevant informationAny other relevant information Where did you hear about usFamily / friendLeafletProfessionalSearch engine & websiteSocial mediaA First Light partner agency
