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 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 3617.

First Response offers 24/7 mental health crisis support 0800 952 1181.

Rape Crisis and Sexual Abuse 24/7 support line freephone 0808 500 222.

Bradford Samaritans freephone 116 123.

If you don’t live in Bradford please call our helpline FREE on 0800 448 0710 for information on services in your area.

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

To self-refer, fill out the required information on the form below.
Click the 'Submit form' button.
The form will be sent securely to the Bradford Rape Crisis Helpline Team.
When we have received your referral one of our staff team will give you a call from our FREEPHONE 0800 448 0710 number to complete the process within approximately 10 working days.
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 *

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.

Main Details

Client type*

First name*

Last name*

Gender

Date of birth (dd/mm/yyyy)*

Service Details

Please select one of the options below.

Please select one of the options below

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

Counselling

Weekly sessions with a qualified counsellor.

The Jyoti services

Specialist services for Black, Asian and Minoritised women and girls, which is run by Black, Asian and Minoritised women. We offer services in a range of languages and are able to access a confidential interpreting service. Jyoti offers a culturally sensitive approach to dealing with issues around rape & sexual violence.

One-to-one counselling
Shared support group
Joity helpline

The Independent Sexual Violence Advocates service

ISVA's work with women and girls aged 13 and over, who have been affected by rape and /or sexual violence at any time in their lives and who are considering reporting or who have reported to the police.

Specialist ISVA support for Black, Asian and minoritised women
Specialist ISVA support for and girls and for young women aged 13yrs and up
Specialist ISVA support for autistic women

Young women and girls services for 13-18 years old

One-to-one emotional support and advocacy for girls at their school or at our offices in Bradford city centre
Specialist ISVA support for with young women and girls aged 13 and over who have been affected by rape and /or sexual violence at any time in their lives and who are considering reporting or have reported to the police.
Therapy group for 14 – 18 year olds

Refugee, asylum seeking and trafficked women’s service

OISC level 1 casework advocacy
Shared support group

Other

A helpline worker will call you back to discuss what services we offer.

Client Contact Details

Address Line 1

Address Line 2

Town

County

Postcode*

Email address

Phone number 1*

Safe to leave a message?*

Phone number 2

Safe to leave a 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
(Include info such as best contact time)

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