Self Referral Form


IMPORTANT PLEASE READ: RASA Merseyside will contact social care, or other relevant agencies, regarding any referral for children and young people under 18 as necessary. If you are age 16 or 17 we will require the contact details of a responsible adult who we can contact with any safeguarding concerns.

Before you begin completing this online form please note we are happy to answer any questions you may have on this number 0151 558 1801. 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.

We are a survivor focused organisation and as such we are unable to accept referrals for anyone who is currently under investigation for committing a sexual offence or anyone who has a conviction for a sexual offence.

Please confirm that the person being referred is not known to Police regarding 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. RASA Merseyside reserve the right to refuse the provision of services.

RASA Merseyside provides support to anyone impacted by sexual violence. We have a counselling service which provides one to one support to work through the impacts of sexual abuse. We also have an ISVA service for anyone who has an ongoing police investigation regarding a sexual offence.

Service Criteria/ Explanation of services

Counselling

We offer counselling to survivors of rape and sexual abuse provided by qualified counsellors and counselling students in their final year of placement. Counselling takes place on a weekly basis depending on the client’s availability. Supporters and carers of survivors may also access this service if they have been affected by the survivors’ experience of sexual violence or abuse.

Please be aware if counselling has been requested, we do have a waiting list.


ISVA (Independent Sexual Violence Advisor)

Our ISVA team are independent specialist workers who can provide practical and emotional support to individuals who have experienced rape or sexual abuse at any time in their life. The worker will support you regardless of whether you are reporting the matter to the police or not.

The ISVA team consists of:

  • Independent Sexual Violence Advisors (ISVAs), who provide support to individuals aged 18+.
  • Children & Young People’s Independent Sexual Advisors (ChISVAs) who provide support to under 18’s. A ChISVA may also work with individuals aged 18-25 where they have additional needs.

Please complete the below form with as much information as possible.

Required fields are shown with a *

Main Details

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Client Contact Details

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Additional Details

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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 provide information about your reason for referral

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

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