Please use this REFERRAL FORM to refer in to the following Support Services:

Horizon accepts referrals from individuals and agencies upon full completion of this form. Please note that, if this form isn't completed in full, it will be returned to the individual or referring agency.

Horizon Services Referral Form

Please confirm that the individual being referred has agreed to this referral being made and consents for us to hold the confidential data being supplied

Please tick box if you agree with the above statement

Please indicate service(s) required

Adult Counselling
For male or female survivors of sexual abuse aged 18+ in the Gwent area.

Select Adult Counselling

Please indicate your preferred way of accessing Counselling:
Face to Face Telephone Online via Zoom

Specialist CYP Counsellor
For 13-17 year old male or female SV victims/survivors.

Select CYP Counsellor

Please indicate your preferred way of accessing CYP Counsellor:
Face to Face Telephone Online via Zoom

ISVA (Independent Sexual Violence Advisor)
Is a victim-focused advisor who works with women, men and children who have been victims of rape, sexual violence or childhood sexual abuse at any time in their life.The support the ISVA provides will vary from case to case depending on your requirements. She can:

Help you decide if you wish to report to the police
Give you information about the legal process and your rights
Support you in all stages of the legal process if you have made a report to the police
Support you when you give evidence in court
Assist you with contacting the police and prosecution service
Talk with you about your situation in a safe space
Listen to you, find out what your needs are and assist you to gain support from other agencies
Work with you whether you decide to report to the police or not.

Select ISVA

Horizon Exploitation Advocacy Support Services
Information, advice, support and advocacy services for women who are currently, or are at risk of, experiencing sexual or financial exploitation. The service can provide practical and emotional support on a structured support or drop-in basis.

Select Horizon Exploitation Advocacy Support Services

Groupwork
Online and/or face-to-face group work.

Select Groupwork

Referral Details

Referring Agency (If Applicable)

Date of Referral (dd/mm/yyyy)*

Referral area (please select the most convenient area(s) for attending support/counselling):
Pontypool Newport Abergavenny Caldicot/Chepstow

Contact Details

Individual requiring support

Client Name

Client Address

Client telephone (home)

Client telephone (mobile)

Your Email Address *

Date of Birth

Please select all the ways the individual is happy to be contacted:
Letter Email Phone Text Voicemail

Professional making referral (if applicable):

Full Name *

Address

Mobile

Diversity

To ensure we continue we continue to fully meet the needs of our diverse client group, it is important that we monitor all forms of diversity. Please indicate if you prefer not to disclose any of this information.

Is this the gender assigned at birth
YesNoDeclined To Answer

Ethnicity

Sexuality

Religion

Do you consider yourself to have a disability:
YesNoDeclined To Answer

If yes, please state type of disability

Marital Status

Parental Status
ParentNot a parentPregnant

If a parent, please select all that apply
Children don't live withSome children live withAll children live with

Do you have any specific support needs
YesNo

If yes, please state (e.g. communication)

GP/Emergency Contacts

GP Details

Telephone

Address

Emergency contact name/relationship to individual

Needs

Does this individual experience any of the following issues:

Mental health
YesNo

Drug Abuse
YesNo

Domestic abuse
YesNo

Alcohol abuse
YesNo

If the answer is "Yes" to any of the above, please give further details including any names and contact numbers for any support workers i.e. drug and alcohol support worker, mental health worker and any treatment provided

Please give us a brief summary of the reason for this referral

Risks

Risk indicator information (e.g. recent self-harm, suicide, medicine):

Are there any risk indicators that you think we need to know about?
YesNoN/A

If the answer is "Yes", please give further details of the risk

Please score the following two scales out of 10 based on the present time (10 highly likely and 0 not likely at all)

Has a Mental Health diagnosis been given recently or at any point in time by a GP, psychiatrist, etc.?
YesNo

If the answer is "Yes", please give further details

Has the individual previously accessed or are they currently accessing any mental health service?
YesNo

If the answer is "Yes", please give further details

Criminal Justice

Is the individual currently receiving support from another Independent Sexual Violence Advisor Service i.e. New Pathways, Sexual Assault Referral Centre (SARC)?
YesNo

If the referral is for the Independent Sexual Violence Advisor service and the client also requires therapeutic support, this will be dealt with at the Initial Assessment and an internal referral will be made if appropriate, or if requested by the client, to ensure clients receive a support package that meets their needs.

Please note: Horizon SV service believes that making a formal complaint to the Police is entirely the choice of the individual and we do not encourage nor discourage anyone from this procedure.

Did the individual attend a Sexual Assault Referral Centre (SARC)
YesNoN/A

Have the Police been involved in any kind of investigation relating to the reason for this referral?
YesNo

If yes, is there a current open investigation regarding the reason for this referral?
YesNo

If there is a current ongoing investigation please provide details of the Officer in Charge (OIC):

Name

Service