RASASC Guildford

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For Surrey Residents

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Get Support
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Call our helpline on 01483 546400 - we are available Monday to Thursday, 7:30pm to 9:30pm

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Rape and Sexual Abuse Support Centre (RASASC)

Independent Sexual Violence Advisor (ISVA)

Self-referral form

*You must reside in a Surrey borough to refer into RASASC Guildford. We can only accept referrals from Surrey residents*

Your details

First name:

Surname:

How did you hear about us?

Date of birth:

Gender:

Preferred pronouns:

How would you like us to contact you?

Mobile Phone

Landline

Email

Text

All

Is it ok to leave a message?

Yes

No

Mobile number:

Landline/other number:

Email address:

Home address: *Required

Postcode* Required

Please indicate which of the below apply to you

Rape

Sexual Assault

Childhood sexual abuse

Do you have any access requirements:

Incident details

Free Text

Police involvement

Has the incident(s) been reported to the police?

Yes

No

Free Text

If YES, please complete the following:

Name of police force:

Date crime reported, if known:

Name of police officer:

Crime reference number:

Free Text

Other services involved, if relevant

Organisation:

Organisation:

Name of contact:

Name of contact:

Contact phone number:

Contact phone number:

Email:

Email:

Free Text

Self-referrals for those under 18-years old

If you are under 18 years of age, we will notify Surrey County Council’s Children Services that we will be supporting you.

Where did you hear about us?

In order to meet the aims and commitments in our equality policy, including not discriminating under the Equality Act 2010, we need to build an accurate picture of who we support in order to encourage equality and diversity. The anonymised data is also required by our funders, and improves our ability to apply for funding. We need your help to enable us to do this, and we’d be grateful if you could complete the following questions:

Do you identify with the gender you were assigned at birth?

What is your ethnicity?

Age

What is your sexual orientation?

What is your religion or belief?

Do you consider yourself to have a disability or health condition?

Free Text

Please read our Privacy Policy to understand how we use your data

Opt-In

I confirm that I have read and understood the RASASC Guildford Privacy Policy, and I consent to you using my data

Thank you for getting in touch.

One of our ISVAs will get back to you within five working days of us receiving your form.

Sorry, there was an error submiting your form.

Please try again later.

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We support survivors of all genders over the age of 13 from across Surrey, who have been raped, sexually abused or have had an unwanted sexual experience.

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All Rights Reserved | RASASC | Registered Charity Number: 1145816 | Company Number: 07858989

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