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’) we will call you from a withheld number or text you or email to arrange a time to speak (if safe to do so). Please note that we have been experiencing a rise in demand and it is currently taking us several weeks to respond but we will contact you as soon as we can. We are not a crisis service and so if you are currently struggling to cope please follow these links:

Crisis numbers

Helplines and Webchat services

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.

Please note that if you are in danger or feel that you are a danger to yourself, the best people to contact is the emergency services on 999.

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

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


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Please provide any information you feel able to about what support you require or what you have experienced

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