Referral Service

The following information helps us select the appropriate specialised counselling centre and remain with the proaktiv – service centre. What may have been the reason the crime was committed against you?

Hostility due to faith/religion/culture
Hostility due to appearance (e.g. skin colour, assumed background, etc.)
Hostility towards people with physical impairments/disabilities
Hostility towards the LGBTIQ+ community
Violence motivated by religion/politics
Violence in the family/relationship (domestic violence)
Other

By sending the form, I am consenting to the following:

1. my personal data provided in this form may be transmitted in encrypted form to the proaktiv – service centre for the purpose of finding support services.

2. my personal data indicated on this form may be processed by the proaktiv – service centre
   for the purpose of finding an appropriate specialised service centre for victims of crime for me.

3. the proaktiv – service centre may forward the personal data from this form indicated in the field with a grey background to the selected specialised counselling centre via an encrypted process.

4. the specialised service centre may use the personal data provided by me in field with a grey background to contact me for the purpose of an initial counselling appointment.

5. even particularly sensitive data provided by me may be processed, if I have included them in the form.

I hereby confirm that I have read the information on data protection.*

I acknowledge that my consent is voluntary. I am aware that my consent has no effect on any police investigation that may be pending. I am aware that I may withdraw my consent to future processing of my personal data at any time, both vis-à-vis the proaktiv service centre and vis-à-vis the selected specialist counselling centre. Consent may be withdrawn on an informal basis (e.g. by email or telephone).*

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