Enquiry form: Organisations


Before you begin

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.

If you are in danger call 999.

If not life threatening call Police on 101

If you live in the Bradford area then use the contact details below in case of an emergency

West Yorkshire SARC offers free support and practical help 24/7 to anyone in West Yorkshire who has experienced sexual violence and/or sexual abuse. 0330 223 0099.

First Response offers 24/7 mental health crisis support 01274 221181

Bradford Samaritans on 01274 547547 or free to call on 116123.

National Rape Crisis Helpline open 12 noon – 2.30 pm and 7 – 9.30 pm every day of the year on Freephone 0808 802 9999.


Complete the Form below with as much information as possible. We may only disclose information with permission from all parties.

We will only accept referrals for those who have agreed to attend and who are aware that the referral has been made. The helpline team will aim make initial contact with the survivor within 5 working days to complete the process.

We will accept referrals for women and girl survivors of sexual violence.

It is helpful for us to be informed by the Referrer of any involvement with other agencies e.g. Social Services, Probation or Mental health Services. Your client needs to have given their consent to this.

Required fields are shown with a *

In line with the current Data Protection Act (1998) and General Data protection Regulations (2018) we will not keep your personal information any longer than is necessary and will dispose securely of any information that no longer needs to be kept.

Referrer Details

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Essential Details

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Client Contact Details

Additional Details

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GP Name / Practice or Surgery Name
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Assault Details (if known)

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(CSA means 'Childhood Sexual Abuse')
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Please tick box below to show consent given for referral to support services*