If you would like to refer a carer, parent or family member to Restitute for support, please use the form below. We welcome referrals from other organisations. If you would like more information about the services we offer, please contact ceo@restitute.org.

Client's name *

First

Last

Any other name the client is known by

Client's phone number *

Client's Email

Client's Postcode *

If you don't know the client's postcode, please state the nearest town.

What information has your client agreed that you can tell us?

What can you tell us about other family members? For example, other carers

Demographics

If you know the following information about the person you are referring, it would help enormously if you can provide it here:

Gender: Is the person you're referring:

• Male
• Female
• Non-binary
• Prefer not to say
• Other

Sexuality: Is the person you're referring:

• Bisexual
• Heterosexual or Straight
• Gay or Lesbian
• Not known
• Other sexual orientation

Ethnicity: Is the person you're referring

• Asian / British Indian
• Asian / British Pakistani
• Asian / British Bangladeshi
• Asian / British Chinese
• Any other Asian background
• Black / Black British Caribbean
• Black / Black British African
• Any other Black, Black British, or Caribbean background
• Mixed or multiple ethnic groups
• Mixed White and Black Caribbean
• Mixed White and Black African
• Mixed White and Asian
• Any other Mixed or multiple ethnic background
• White English, Welsh, Scottish, Northern Irish or British
• White Irish
• Gypsy or Irish Traveller
• Roma
• Any other White background

My pronouns are:

• He/Him
• She/Her
• They/Them
• We/Us
• Something different

Please indicate if your client is a: *

• Primary victim / survivor
• Third Party victim (ie family member or carer)
• Both

Please note: we only support primary victims who are caring for other victims / survivor

About the referrer

How did you hear about Restitute? *

Organisation name

Contact name *

First

Last

Email *

Telephone number

Apart from your organisation, who else is involved with your client?

• Police
• Social Care Services
• Independent Sexual Violence Advocate
• Independent Domestic Violence Advocate
• Other organisation
• None

GDPR Agreement *

• My client consents to Restitute storing their submitted information.

Consent to contact *

• My client is aware that Restitute will contact them once this form is submitted.

Name

Submit