Self Referral Form

This form is for self-referrals only. Professional/Agency referrals must be submitted by this separate online form.
Click here for the Professional/Agency Form

If you have experienced sexual violence or abuse at any time in your life and are looking for help and support in London, you can contact us on 0808 801 0860 or submit the form below.

If you have recently been assaulted you may wish to consider contacting the Havens

After you submit the form below a specially trained worker (called a ‘Navigator’) will call you back within 48 hours Monday to Friday. This will be from a withheld number. 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.

When you speak to us, we will ask you some questions so we can understand the type of support that you might need. We will then explain what London services are available to you and make referrals on your behalf if you wish.

We will not ask you to describe what happened to you.

Privacy and Data Protection

Information submitted on this form is sent securely to the data management system of the Women and Girls Network (who run the London Survivors Gateway). 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.

Please tick here to confirm that you understand our confidentiality and information sharing policy and that you consent for us to contact you and store the information you share with us on our data management system. (tick box)*  

Main Details

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Do you identify as trans or having a trans history?
Contact Details

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Additional Details

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