Please indicate whether you are completing this form for yourself or on behalf of someone else, then complete the form that will appear below fully to submit your referral.
A member of the Horizon team will respond within 5 working days. If you have any questions, please contact us.
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.
Please indicate service(s) required
Individual requiring support
Professional making referral (if applicable):
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.
Does this individual experience any of the following issues:
Risk indicator information (e.g. recent self-harm, suicide, medicine):
Please score the following two scales out of 10 based on the present time (10 highly likely and 0 not likely at all)
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.
If there is a current ongoing investigation please provide details of the Officer in Charge (OIC):
Form Completed By
You will need to confirm you accept and agree with the statements at the top of this form before proceeding