SurvivorsUK | Self Referral Form

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Self referral form

If you are looking to refer to our Independent Sexual Violence Advisor service, please complete the form via this link.

Step 1 of 3

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Section 1 - Personal Details

First Name(Required)

Last Name(Required)

Date of birth(Required)

DD slash MM slash YYYY

Please indicate which methods you are happy for us to contact you by:*(Required)

Phone call

Email

Post

Please include all methods you are happy for us to contact you by as this will make it easier for us to get in touch.

Phone Number(Required)

Are you happy for us to leave a voicemail on this number?(Required)

Yes

No

Are you happy for us to text you on this number?*(Required)

Yes

No

Email Address(Required)

Address(Required)

If you currently have no fixed abode, please enter "NFA" as your address.

Street Address Address Line 2 City County Post code Country

Emergency contact

Name of emergency contact(Required)

If you prefer not to provide this information, please write N/A

Contact details(Required)

If you prefer not to provide that information, please write N/A

Section 2 - Service You're Interested In

If you are interested in more than one service, or are unsure which service you would like to access, please use our webchat service or call us on 0203 598 3898.

Please indicate which service you would would like to refer to:*(Required)

Groupwork

Counselling - Face to face

Counselling - Video or telephone call

Note: If you wish to apply to our Independent Sexual Violence Advisor service, please complete the ISVA self-referral form.

Please note that at your initial meeting, you will be asked if you have a gender preference for your allocated counsellor. If you have any queries about this before your initial meeting, please don't hesitate to contact us.

Please note that our waiting list for counselling services is currently 6-9 months, and that we charge for this service. We have a sliding scale of suggested fees. Fees are calculated on a sliding scale, according to income and your outgoings, with the lowest charge being £5 per session. However, please do not let financial difficulties get in the way of you attending your assessment. Any fees can be negotiated according to your circumstances. Any agreed payment can be made in cash or online.

Section 3 - About You

Please complete the questions below - we ask these for monitoring and reporting purposes. If you don't feel comfortable answering any of them, that's ok - just leave them as 'prefer not to say'.

What is your ethnicity? *(Required)

What is your sexual orientation? *(Required)

Do you identify as transgender? *(Required)

What is your gender identity? *(Required)

What are your pronouns?

Do you consider yourself to have a disability or long-term health condition? *(Required)

Yes

No

How do you describe your disability/long-term health condition?(Required)

Chronic illness

Learning disability

Mental health

Mobility

Physical condition

Sensory impairment

In another way... (please describe)

Disability/long-term health condition not included on list above:(Required)

Is there anything else you would like to tell us?

* Your details are safe with us - read our privacy policy

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© 2025 SurvivorsUK. SurvivorsUK is a charity company limited by guarantee (Company No.3792760) | Registered Charity No. 1077484 (England & Wales)

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Helpline Closure (04/05/2025)

We will be closed between 12-4pm due to staff shortages.

We will be open from 4pm-8pm as usual

If you need to speak to someone urgently while we are closed, please call Safeline on 0808 800 5005.

1:1 chat sessions with trained support workers, in confidence.

We are here for any man, boy or non-binary person who has ever experienced unwanted sexual activity (such as words, images or touch). We are also here for loved ones supporting a survivor in their lives.

To learn more about our privacy and confidentiality policy click here.

Mon – Sun
12pm-8pm

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Chat via SMS text
020 3322 1860

Info Leaflets and Cards

Please find a selection of useful SurvivorsUK materials below, which can be downloaded via the Download links.

SurvivorsUK Business Cards

A Guide to Our Services – Leaflet

Dancing With Our Ancestors – Poetry & therapy booklet by Black, Asian and Mixed heritage survivors

Training

SurvivorsUK offers professional training on providing services to male survivors and the impact of sexual abuse and rape on men and boys. We offer this training to individuals and organisations at competitive rates from our premises in East London or, depending on numbers, at a rented space nearby.

To make a booking please complete the booking form and email it to info@survivorsuk.org, or call 020 3598 3898.

Upcoming Training Events

Bespoke Training

Depending on availability, we may be able to offer bespoke training packages to organisations at your premises.

Trainer: Dr Katherine Cox
Lunch provided.

Rates

Large organisations £150 per person (or £120 pp for 3+ bookings)
Small organisations or individuals £100 per person (or £75 pp for 3+ bookings)

Dates

Saturday 23 May 2020
10am to 4pm

Enquire about this course

No training events are currently planned

Enquire about our training

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