Lamplight API response

First name

Last name

Address 1

Postcode

Email address

Mobile phone

Phone number

We will need to contact you following your referral. Please ensure that you share permission contacts with us so we are able to reach you in the way that suits you. Please note that our text system can often be the fastest and easiest way to contact us.

By post

By email

By mobile

By text message

Other information

Contact and Client Details (we ask for details around protected characteristics to ensure our service is accessible for all. Please answer what you are comfortable to share)

Send a text message (via our Text Magic messaging system)

Date of birth

Pronouns

Gender

Gender- other

Sexuality

Ethnicity

Any accessibility needs (e.g. learning difficulties, disabilities)

Information disclosed

Single or multiple assaults

Disclosure details (in your own words please share what you are comfortable to about the experiences that bought you to SARAC)

Recent (within the last 12 months)

Childhood Sexual Abuse (CSA)

Childhood Rape

Childhood Sexual Assault

Childhood Domestic Abuse

Childhood Sexual Exploitation (CSE)

Adult Rape

Adult Sexual Assault

Adult Domestic Abuse

Adult Sexual Exploitation

Adult Sexual Abuse

Adult Sexual Harassment

Secondary Survivor

Not Applicable

Historical (over 12 months ago)

Childhood Sexual Abuse (CSA)

Childhood Rape

Childhood Sexual Assault

Childhood Domestic Abuse

Childhood Sexual Exploitation (CSE)

Adult Rape

Adult Sexual Assault

Adult Domestic Abuse

Adult Sexual Exploitation

Adult Sexual Abuse

Adult Sexual Harassment

Secondary Survivor

Not Applicable

Was legal action taken?

Criminal Justice Process completed?

Trauma Responses

Flashbacks

Anxiety/Panic attack

Depression

Blank out/ lose time

Any other mental health issues as a result of the trauma?

Coping Mechanisms

Self-injury

Suicidal thoughts or attempts

Drug and/or alcohol use

Any other challenges unrelated to sexual abuse? (Additional information shared)

Have you ever had specific support for sexual violence from SARAC or anyone else?

What are you hoping to achieve from support?

Referer information (if you are referring on behalf of somebody else, please give details of your relationship to the client and contact details)

How you hear about SARAC?

By clicking "Submit Referral" you consent that we may store the information you have provided for the purposes of processing your referral. Please see our privacy policy for more information.

You can read our privacy policy here

Young Person Referral Form (11-17)

Other information

Contact and Client Details (we ask for details around protected characteristics to ensure our service is accessible for all. Please answer what you are comfortable to share)

Information disclosed

Trauma Responses

Coping Mechanisms