Self Referral – Online – Devon Rape Crisis and Sexual Abuse Services

Data Protection*
By ticking this box you are giving your permission for Devon Rape Crisis and Sexual Abuse Services to hold your information. More details on how we store information and GDPR can be found on our Data Protection page.
- I give permission for Devon Rape Crisis and Sexual Abuse Services to hold my information
First Name*
Last Name*
Date of Birth*
Date Format: DD slash MM slash YYYY
Address*
Street Address Address Line 2 City County Postal Code
Mobile Telephone*
Is It OK to Text or Leave a Voicemail Message?*
- OK To Text
- Do Not Text
- OK To Leave a Message
- Do Not Leave a Message
We will need to talk to you, please let us know when are the best days/times to contact you (please note this will need to be within our office hours - Monday-Thursday 9-5 and Friday 9-4)*
E-Mail Address*
Home Telephone
Is It OK To Leave a Voicemail Message?
- OK To Leave a Message
Preferred Contact Method*
Registered GP Surgery*
Name of GP (if known)

Sexual Offences
Are you currently being investigated for, or have you been convicted of, a sexual violence offence?*
- No
- Yes
We do not offer support to anyone who has been charged or convicted of sexual offences or who is currently under investigation for such offences. Please make a referral to an organisation such as 'Survivors Trust' and 'Stopitnow' who are specialised in providing this support

Background

Brief overview of incident(s) / why you’re seeking support at this time - we do not need you to go into great detail.
Incident*
Single or Multiple Incidents?*
Was this within the past 12 Months?*
Relationship to perpetrator, including their gender (e.g. male family member, female partner etc.)*
Do you have any contact with the perpetrator now? (If yes please give further details)*
Have you disclosed this information to someone before? (If yes, to whom?)

Support
Are you at risk (are there any concerns about your safety / risk of harm / safeguarding)? Please list any concerns, even if unrelated to the sexual violence*
Have you experienced any Domestic Abuse within the past 6 months? (If yes please give details of support in place)*
Which other services, if any, are you currently receiving support from? (Please indicate whether you are happy for us to share information with them)*
Which other services, if any, are you currently waiting for support from? (please indicate whether you are happy for us to share information with them)*
Do you have any individual needs for attending an initial meeting? (e.g. Location, days/times, language, mobility, disability access etc.)*

Sexual Offences