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.
Please note we do not provide a crisis service, in emergency please contact 999.
If you are unsure if your referral is suitable or have any further questions please contact us on 01229 820828 or 01524 239595 before completing this referral form
If you have experienced sexual violence or abuse at any time in your life and are looking for help and support then please complete the form below
If you have recently been assaulted you may wish to consider contacting :-
The Bridgeway Service in Penrith (Cumbria) or The Safe Centre in Preston (Lancashire)
We are able to offer services to:
- Adults, Children and Young people living in Cumbria and Lancashire and surrounding areas
- People of all genders
- Children and Young people aged 4 and above
- People who have experienced some form of sexual violence or abuse in their lives
- People who consent to being contacted by us to discuss their support options in relation to their experience of sexual violence/abuse specifically
To understand your clients' current needs, we also ask them to complete a brief survey –
Adult Referral Needs Assessment
Children & Young People Needs Assessment (ages 4-17)
After you submit your forms and information, a member of the team will either contact you for more information or send you more information about our services (please ensure you tell us clearly in the form how you wish to be contacted) We will always use a withheld number if we call you.
Our service is bound by a strict code of ethics around confidentiality. All our services work to ensure the highest levels of confidentiality, extending to how we store any information and we are governed by GDPR rules.
However, there are exceptions where there is a moral and/or legal duty to breach confidentiality and this applies to any information shared at the referral stage including;
Prevention of serious harm to the individual or another person.
Certain child protection situations.
Knowledge of acts of terrorism or another illegal act.
We are a survivor focused organisation and as such we do not accept referrals for anyone who is subject (the suspect) to an ongoing police investigation for sexual or violent offences, or for anyone who may pose a risk of harm to others.
Please confirm that you do not pose a risk of harm to others, and are not known to Police regarding violent or sexual offences (tick box)*
Information submitted on this referral form will be treated as confidential and stored securely on the Birchall Trust’s data management system. Information is only shared with third parties with the explicit consent of the person being referred or if there is a risk of significant harm or safeguarding concerns.
Required fields are shown with a *