Self Referral Form

Before you begin completing this online form please note we are happy to answer any questions you may have however, we do not provide a crisis service. In case of an Emergency please call 999.

IMPORTANT PLEASE READ: Before submitting a referral please pay attention to the Information within the Service Details section or take a look at our website ‘Get Help’ tab (all the services we provide), this will help you when choosing what service is right for you. If you are unsure about which service to refer to, then please feel free to contact the office on 01325 354 119 or email: info@rsacc-thecentre.org.uk.

We offer free, safe support to anyone over 13 who has experienced any form of sexual violence at any time in their lives.

We can accept referrals from anyone who lives, works or is accessing education from the following postcode areas: DL1 - DL17, DH1 - DH9, SR7 - SR8, TS21, TS27 - TS29, NE16.

Please complete the below form with as much information as possible.

Required fields are shown with a *

Main Details

About you*

First name*

Last name*

Gender

Date of birth (dd/mm/yyyy)

Service Details

Please select one of the options below.

Services

Service criteria /explanation of services (Click here to show/hide details)

Client Contact Details

Address Line 1

Address Line 2

Town

County

Postcode

District*

Email address

Phone number 1

Safe to leave a message?

Phone number 2

Safe to leave a message?

Prefer Text Message

Other contact method

Additional Details

Person is aware*

Are you are completing this form on behalf of someone else, if yes please provide your name and relationship to the above named person; in the comments box below. (Please note we can only accept this enquiry if the named person on this form is aware).

Where did you hear about this site?

Please enter any comments below

Please tick box below to show consent given for referral to support services*