SurvivorsUK | Self Referral Form

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Self referral form

To make a referral to either our counselling or group work programmes, complete the form below.

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

How did you hear about SurvivorsUK's services?(Required)

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)

Group Work

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 consultation 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 15-18 months.

People deal with trauma differently and what helps one person to heal may not work for another. We offer different types of counselling so we can help find the technique that works best for you. These include:

Talking therapy: An opportunity to talk to a trauma-informed professional about your thoughts, feelings and behaviours in a safe, confidential space, and help you to move forward from traumatic experiences.
Trauma-focussed CBT: Cognitive behavioural therapy adapted for those affected by trauma. This technique helps to make sense of thoughts, feelings, and behaviours, and develop healthier coping strategies.
EMDR therapy: Eye movement desensitisation and reprocessing therapy uses eye movements or other sensory techniques to help the brain process difficult memories. This can help reduce anxiety, flashbacks, and emotional distress.
Psychosexual therapy: This method helps with sexual and intimacy issues linked to trauma. It focusses on building trust, confidence, and a healthier relationship with sex.
Art therapy: Art therapy uses creative activities like drawing or painting to explore emotions, build self-awareness, and support mental wellbeing. It can be especially helpful when words are hard to find.

Once your referral form has been processed, you will receive an email or phone call from a member of the groups team to arrange an appointment for an assessment. This is a chance for you to get to know us better and collaboratively explore if a group is right for you. If there is a particular group you would like to join from our current offering (View groups here), please indicate in the box below:

Please indicate if you are interested in any particular groups

If you are unsure at this stage, that is perfectly okay. We can talk through options with you during your initial consultation call.

CORE group

Tune-in Tuesday, Wednesday Wellness or Get Together open groups

Allies group for people supporting survivors

Black, Asian and Mixed Heritage survivors group

Trans, Non-binary and Gender Questioning group

Young People's group for survivors aged 18-24

Sex and Intimacy discussion group

Chemsex survivors

Creative Writing in Nature and/or Online group

This field is hidden when viewing the form

Please indicate which forms of counselling you might prefer

If you are unsure at this stage, that is perfectly okay. We can talk through options with you during your initial consultation call.

Talking therapy

Trauma-focussed CBT

EMDR therapy

Psychosexual therapy

Art therapy

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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Info Leaflets and Cards

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

Information for Male Survivors of Sexual Abuse and Rape

A Guide to Our Services – Leaflet

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

SurvivorsUK Business Cards

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 [email protected], 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

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, or any survivor who thinks our service is right for them. Talk to us by phone, webchat, WhatsApp, or SMS text.

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

Mon – Sun
12pm-8pm

Chat Online Now

Call 0808 801 0332
(Monday-Friday, 10AM-12PM only)

Message us over WhatsApp or SMS text
0786 003 1252