Self Referral Form

Welcome to our online self-referral form

Self-referring means you can contact us directly to access support. To self refer we will need you to answer a few questions. If there is a * by that question, this means that you must answer this to submit the form.

To self-refer, fill out the information and click the 'Submit form' button. Once we have received and processed this form one of our staff team will give you a call to arrange a telephone assessment. You can expect a call from us in less than five working days. If it is not convenient for you when we call, we will arrange a suitable time to call you back. When we call you, you will have the opportunity to ask any questions you may have and we will ask you for some more information about why you need to access support with us.

Our Criteria for support

We support anyone who lives or works in Lincolnshire, who has been affected by any form of sexual violence at any point in their lives and is willing to engage in support/therapy relating to these experiences. If you meet these criteria please tick this box *  .

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.

By ticking this box, you agree for checks to be made regarding your risk status, or that of the person being referred. LRC reserve the right to refuse the provision of services. I confirm that I (or the person being referred) do not pose a risk of harm to others. Please tick this box to confirm this. *  

Main Details

Contact Details

Additional Details

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