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 01905 611655 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.

If the person being referred is U18 they can be referred directly to the West Midlands Children and Young People’s Service (CYPS) which is a bespoke service for children and young people. They will be seen by a paediatrician to ensure all the needs of the child or young person are addressed including medical and emotional. If counselling is recommended the child or young person will receive counselling.

To make a CYPS referral telephone: 0808 196 2340 (a single point of contact, 24 hours a day, 7 days a week, 365 days a year).

Please complete the below form with as much information as possible. We may only disclose information to the referrer about the service user’s attendance with written permission from all parties.

Required fields are shown with a *

Main Details

Client Contact Details

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*