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Where we ask for contact details, it is only mandatory to provide us with at least one of these, such as an email address or phone number.

If you would like immediate help during opening hours please contact the helpline (0300 303 1056) or live chat service.

All fields marked with * are required.

Referrer Details

Would you like to request support for yourself, or for somebody else?
Referrer Type
Is it ok for us to leave you a message?
How would you like us to contact you?

We aim to respond within 48-72 hours

Client Details (for Church/Police/Agency referral only)

Has the client consented to the referral?
Ok to leave message/send text?
Ok to speak to others in household?

If there are any times the client would like to avoid, or if they have any preferred times, please specify them at the end of the form.

Our operating hours are:

Monday, Tuesday, Wednesday, Friday, Saturday: 10am-6pm

Thursday: 12pm-8pm

Safe to send letter?
Preferred contact method

The following ED&I information is optional, however, it is useful information for the service to monitor our accessibility to survivors.

Translator required?

Incident Details (for Church/Police/Agency referral only)

It is helpful for us to have this information to be clear that our service can help and to prevent the survivor having to repeat sensitive information

The client does not have to have reported the abuse to anyone in order to be eligible for support but it is helpful to know if it has been reported.

Reported to the church?
Reported to police?
Reported to other?