Self Referral Form

The Rape & Sexual Abuse Support Service understand that it takes courage to seek support.

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.

IMPORTANT PLEASE READ: If you would like more information about our services, please contact the office on 01494 513823 or send an email to the following email address:

Please complete the below form with as much information as possible. We may only disclose information to the referrer about the service user’s attendance with written permission from all parties.

Required fields are shown with a *

Main Details

Client Contact Details

Additional Details

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