Self Referral Form

Before you begin

This form is for adult survivors of sexual violence or abuse who would like to come to CSASS for counselling. We can also support family members, friends and professionals who are also affected by the impact of the abuse – usually through supporting a survivor they are close to.

Please fill out the information and click the 'Submit form' button.

The form will be sent securely to Chester Sexual Abuse Support Service. We will give you a call to arrange a first meeting. At this appointment you will be able to ask questions, and we can decide together what support is right for you.

Required fields are shown with a *

Main Details

Are you a :-

First name*

Last name*

Gender*

Please see our Equality and Diversity policy, available on our website, for more information

CSASS supports adults over the age of 18. If you are under 18, please contact RASASC (who are able to support survivors under 18 in our area), on 0330 363 0063 or rapecentre.org.uk/contact.php

Contact Details

Address Line 1

Address Line 2

Town

Postcode

Email address

Phone number 1*

Safe to leave a message?

We may phone you, but we won’t text or leave voicemail, until you’ve told us that’s ok. Phone calls from us will appear as No Caller ID or anonymous

Additional Details

Where did you hear about this site?

Is there any other information it would be useful for us to know about? (you can leave this box blank if you prefer)

We are an organisation for survivors of sexual violence and abuse. We don’t offer services to people who are being investigated by the police for sexual, domestic or violent offences, or anyone who may pose a risk of harm to others. Please confirm you are not being investigated for these offences, and does not pose a risk of harm to others (tick box)*

CSASS will keep your personal information accurate, up-to-date, secure and confidential, and only for as long as needed in order to support your needs and improve the service. You can ask to see your personal information held by CSASS usually within a month of asking. CSASS will not share your personal information with anyone outside CSASS without your permission, unless required by law, or to prevent immediate harm (and in these cases, CSASS intend to seek your consent and keep you informed).