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.

Self-referring means you can contact us directly to access support.

IMPORTANT PLEASE READ: Before submitting a referral please pay attention to the information within the Service Details section, this will help you to refer into the correct service/s. If you are unsure about which service to refer to, then please feel free to contact the office on 01782 433204 or email:

We are a survivor focused organisation and as such we do not accept referrals for anyone who is subject (the suspect) to an ongoing police investigation for sexual, domestic or violent offences, or for anyone who may pose a risk of harm to others.

Please confirm that the person being referred does not pose a risk of harm to others, and is not known to Police regarding violent or sexual offences (tick box)*  

This referral cannot be submitted unless the above information is confirmed. By ticking this box, you and the person being referred agree for checks to be made regarding their risk status. We reserve the right to refuse the provision of services.

Once we have received and processed this form one of our staff team will call you to arrange an initial telephone appointment. You can expect a call from us in within five working days. If it is not convenient for you when we call we will arrange a suitable time to call you back. When we call you, you will have the opportunity to ask any questions you may have and we will ask you for some more information about why you need to access support with us.

Service details

Service Details/ Explanation of services (Click here to show/hide details)
Main Details

Client Contact Details

Please only enter the first part of your Postcode. We only accept referrals in Stoke on Trent (ST1,2,3,4,6),
Additional Details

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).

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