Enquiry form: Survivors, family and friends

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 live within Teesside then use the contact details below in case of an emergency.

SARC Teesside provides a 24/7 advice line for professionals and Survivors of sexual assault. You can contact them on 01642 516888.

Or you can contact Teesside Samaritans on 01642 217777.


IMPORTANT PLEASE READ: Before submitting a referral please pay attention to the Information within the Service Details section, this will help direct you to the correct service/s.

Select the drop down box named (Service criteria/explanation of services).


Please note: This form is currently being developed and we would ask you to contact the service if you haven't heard anything after 7 working days

There are just a few simple steps for you to take to help us offer you the right support.

  1. To self-refer, fill out the required information on the form below.
  2. Within the service details section, please read the service criteria/explanation of services before you select the service you require.
  3. Click the 'Submit form' button.
  4. The form will be sent securely to Arch North East Referral Team.
  5. When we have received it one of our staff team will give you a call to complete the process within approximately 4 working days, we will then complete the referral process with you. We will not ask or discuss anything intrusive over the phone.
  6. Upon this call you will have the opportunity to receive information about our services. This is when you can ask any questions to help you decide about the type of support you would like to receive.

Required fields are shown with a *

Main Details

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Service Details

Please select at least one or both of the options below, do not leave both as 'None'.
Service criteria /explanation of services (Click here to show/hide details)
Client Contact Details

If the survivor/victim does not reside in any of the listed districts, please contact Referral Team on 01642 822331 / 01642 822335
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Additional Details

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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*