Swindon & Wiltshire SARC Step 1 of 8 - Who are you making a referral for? 12% Please note that the Swindon & Wiltshire Sexual Assault Referral Centre only accepts referrals for individuals 18years or over. For children and young people under the age of 18years, please contact the specialist regional paediatric Sexual Assault Centre, The Bridge If you are looking for support for a rape or sexual assault that has occurred within the past 10 days, do not submit this form, instead, please call us on 01793 781 917 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 number*Email Are you* Friend or relative Professional ProfessionPlease describe your relationship to the person you are referringDo you have any safeguarding concerns? Yes No Please outline the nature of your concerns and provide details of the steps taken to safeguard.*Agency 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 of the person wishing to access the SARC support.Preferred namePronouns 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 voicemail?* Yes No Is it safe to receive a text message?* Yes No Any additional information to make contact safely?When is the best time to make contact?Please tell us the times that would be preferable for contact.What is not a suitable time to make contact?Please tell us the times that would be not be preferable for contact.Are you able to communicate in English?*No difficultySome difficultyNo understandingIs an interpreter required? Yes What language is required? 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 Sexual Assault Other Sexual Offences against an Adult. Rape of a Child under 13 Assault of a Child under 13 by Penetration Sexual Assault of a Child under 13 Other Child Sex Offences Online Sexual Grooming Other Time of incident* Within 10 days (do not submit this referral form, call 01793 781 917) Within 1 month Within 3 months Within 6 months Within 12 months Over 12 months Age at time of incident*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 What is the relationship to the person wishing to be referred to SARCIn what town did the abuse, violence or assault take place*Where did the abuse, violence or assault take place?* Victims home Assailants home Home shared by victim and assailant Hospital/care home Hotel Entertainment venue Public building Vehicle/transportation Outdoors Social media Other address Number of perpetrators*Unknown123456moreAt 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 You don't need to report to the police to access SARC supportCrime Reference (state “N/A” if not applicable or “not known” if not known)*Date reportedStatus of investigation? There is an on-going criminal investigation. There was an investigation that has since closed within the past 3 months. There was an investigation that has since closed within the past 6 months. There was an investigation that has since closed within the past 12 months. There was an investigation that has since closed within the longer than 12 months ago. Has there been a court case? Within last 12 months Longer No Is there a restraining order or injunction?* Yes No More about the person accessing SARC supportWe 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 responsibilitiesKnown learning difficulty?* Yes No Prefer not to say Please provide details*Known physical disability?* Yes No Prefer not to say Please provide details*Known mental health issues?* Yes No Prefer not to say Please provide details*Known self-harm?* Yes No Prefer not to say Please provide details*Known suicidal ideation?* Yes No Prefer not to say Please provide details*Are you alcohol or drug dependent?* Yes No Prefer not to say Please provide details*Are any other professionals providing support?* Yes No Prefer not to say Please provide details* Any other relevant informationWhat would you like to achieve from making this referral?Any other relevant information Where did you hear about usFamily / friendLeafletProfessionalSearch engine & websiteSocial mediaA First Light partner agency
