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 0330 3630063.

If the incident has happened very recently your health is a priority to us so we would advise you to go and see a medical professional if you haven’t done so already. You can go to a local sexual health clinic or to your local hospital or GP and they will be able to offer you advice surrounding your sexual health.

A Sexual Assault Referral Centre can discuss your sexual health needs and may offer a forensic medical examination– evidence can then be stored if you have not yet decided whether or not to report to the police. If you live or have been raped/assaulted in Merseyside your local SARC is SAFEPlace Merseyside. Please contact them on 0151 295 3550. If you live or have been raped in Cheshire please ring 0161 276 6515 to access the service of St Mary's SARC.

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. RASASC reserve the right to refuse the provision of services.

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We aim to offer a confidential service. However, if we are concerned about your welfare or the welfare of others, then we may share the information with appropriate external agencies. (tick box)*  

Once we have received your details from this form, we will contact you to obtain more information in order to open you up as one of our clients. Please tick this box to confirm that you give us permission to contact you on the number provided. (tick box)*  

This is a dropdown box showing an explanation of services (Click here to show/hide details)
Main Details

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Contact Details

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Incident Details

Additional Details

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Are you completing this form on behalf of someone else? (we can only accept referrals where the person is aware)