Self Referral Form

Before you begin

Ben’s Place is unable to offer support to those who are under investigation or have convictions for sexual offences.

Self-referring means you can contact us directly to access support.

This form is currently being developed and as a result we would ask you to contact us if you haven't heard from us after a couple of days in case there has been an issue with the form posting.

If you are a friend or family member you can make the referral for the survivor – however please note:

We may only disclose information to the referrer about the client’s attendance and any issues discussed with the written consent of the client.
We will only accept referrals for male survivors who have agreed to connect and who are aware that the referral has been made.

There are just a few steps for you to take to help us offer the right support.

Please fill out the information and *click the 'Submit form' button. The form will be sent securely to Ben’s Place. When we have received it, we will contact the survivor via email or text to arrange a virtual or telephone chat. This will allow us together to explore information about Ben’s Place services. This is when you can ask any questions to help you decide the type of support you would like to receive.

Required fields are shown with a *

Main Details

Client type*

First name*

Last name*

Gender*

Date of birth (dd/mm/yyyy)*

Contact Details

Postcode

District*

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

Person is aware*

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).

Where did you hear about this site?

Please enter any comments below