Adult therapy professional referral form

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This form is for professionals to refer those who have experienced domestic abuse to our short-term 1-1 Therapy service. This is not a service for clients who are high risk or currently in crisis. We are a low-cost therapy service so please ensure your client is aware of this before referral. Please complete the referral form below and we will contact the survivor to assess what we can do to support them.


RISE Adult Therapy Service Referral Form

RISE's Therapy Service supports the following people - please confirm that each of these conditions is met:
• People who live in Brighton and Hove 
• People who have been impacted by some form of domestic violence or abuse in their lives 
• People who consent to being contacted by us to discuss therapy in relation to their experience of domestic violence and abuse specifically 
• People who are not currently in crisis or at risk 
We offer counselling and therapeutic support to 2 cohorts of adults. Please indicate which service you are referring them to:
Please note: these two services may vary in terms of availability

Safeguarding

We require professional referrers to ensure that survivors of domestic abuse being referred for therapy have appropriate support for any ongoing domestic abuse risks or concerns

Has this person been heard at MARAC in the last three months?
What is the DVA risk to this person?
How was this risk assessed?

⚠️ Please refer to MARAC

We cannot accept referrals of people at current high risk of DVA harm into the therapy service. Please ensure that all appropriate referrals have been made for this person i.e. MARAC, Victim Support Domestic Abuse Support Service.

I confirm that the required action has been taken for all other safeguarding needs before making this referral. 
GDPR and Consent
All information is confidential and stored securely on the RISE servers. Information is only shared with third parties with the explicit consent of the person being referred or if there is a risk of significant harm/safeguarding concerns 
Would you like a copy of this referral sent to the above address?
Consent
Client Address
Is it safe to: 
Preferred contact method (tick all that apply):
Does client have children under 18? 
Does client have any other dependents? 

To help us meet your client's needs, please give us some more details about them

Disabilities

Does your client have any of the following disabilities? (Tick all that apply)

Does your client have any of the following accessibility requirements?

Tick all relevant boxes

Mental Health History and Diagnoses

Is your client okay communicating in English?
Does your client need an interpreter?

Your clients ethnicity

Please give us more information