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Horizon can accept referrals from agencies as well as self-referrals

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.

Horizon Services Referral Form


Please indicate service(s) required

Counselling
This service has been set up to provide counselling to female and male adult survivors of sexual abuse who live in the Gwent area. Free confidential counselling (up to 20 sessions) is available to any adult living in the Gwent area who is currently experiencing or has in the past experienced sexual abuse.

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

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.

SEASS (Sexual 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.

Sexual Violence Recovery Toolkit
12-week programme that helps survivors who are in a position to take part in a group and develop positive lifestyle and coping strategies.

Peer Support Group
Bringing together individuals with shared experiences to support each other.

Family & Friends of Survivors Wellbeing Group
If someone close to you has been a victim, it can feel frightening. Being in a group can help friends/family of survivors, as well as their loved ones.


Referral Details



Contact Details

Individual requiring support


Professional making referral (if applicable):


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.








GP/Emergency Contacts


Needs

Does this individual experience any of the following issues:






Risks

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)






Criminal Justice


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):


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