Self-Referral Form

(for survivors of sexual abuse or their supporters)

This form is for survivors and their supporters to refer themselves for support. If you are a professional working with agency and would like to refer a client, please click here

We have closed the following Counselling waiting lists for:
Adults in Brighton and Hove
Young People in East Sussex
Please see the about/news and blogs section on our website for more details

If you have experienced sexual violence or abuse at any time in your life and are looking for help and support in Sussex, you can contact us on 01273 203380 or submit the form below. We also support people who were abused in the Diocese of Chichester or are a victim of a sexual assault in a case that is going to court in Sussex.

If you have recently been assaulted you may wish to consider contacting the Saturn Centre for free and confidential health care for those after assault.

After you submit the form, a member of our Welcome Team will contact you within one week. They will call you to arrange a convenient time for an appointment. We will not ask you to describe what happened to you.

If you do not answer their call, they will text or email you if you have told us that it is safe to do so. If you need more immediate support, please look at our crisis support and helpline webchat services pages:

Crisis numbers

Helplines and Webchat services

Privacy and Data Protection

Information submitted on this form is sent securely to our data management system. We will not share this information with anyone outside of our organisation without your explicit consent and will only make referrals to other organisations if you agree for us to do this on your behalf. The only time we may have to share information without your consent is if we are concerned you are at risk of significant harm or if there are other safeguarding concerns.

Click here to read full details about how we handle your data and protect your confidentiality.

Anti-bullying and Anti-harassment statement

We are committed to providing a workplace where all employees are treated with dignity, courtesy, and respect. As part of our Anti-Bullying, Anti-Harassment, and Sexual Harassment Policy, we maintain a zero-tolerance approach to any form of bullying, harassment, or discriminatory behaviour toward our staff. This includes conduct by customers, clients, contractors, suppliers, or any third parties.

Please tick here * to confirm that you:

Understand our confidentiality and information sharing policy.
That you consent for us to contact you and store the information you share with us on our data management system.
Agree with our anti-harassment and anti-bullying statement.

Details of the person who would like support

First name*

Last name*

Gender Identity

Trans identity or history

Do you identify as trans or having a trans history?

Date of birth (dd/mm/yyyy)

Contact Details

District*

Postcode

Email address

Phone number 1

Safe to leave a message?

Phone number 2

Safe to leave a message?

Prefer Text Message

Other contact method

Additional Details

Where did you hear about this site?

Is there anything else you would like us to know before we contact you? *
To help us give you the best support possible, if you can, please tell us:

Which services you are referring into:
- Trauma Sensitive Yoga
- Create & Connect group
- Peer Support Group – please specify the name of the group
  - Maple
  - Cedar
  - Aspen
  - Oak
- Adult Independent Sexual Violence Advisor (ISVA)
- Young Peoples Groupwork
- Child, or Young Persons ISVA
If you would like support from our Adult ISVA service (for rape or serious sexual offences, including attempts or sexual abuse in childhood), type “CJISVA - yes”. If not, our Welcome Team will help you find the right support.

It won't affect us contacting you if you don't have any details - please just write none and we will be in touch shortly. To expand, pull the bottom right of input box.