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
Home Telephone
Is It OK To Call or Leave a Message?
- OK To Call
- OK To Leave a Message
Mobile Telephone*
Is It OK To Call, Text or Leave a Message?*
- OK To Call
- OK To Text
- OK To Leave a Message
We will need to talk to you. Please tell us when is best to phone, and if we can leave a message.*
E-Mail Address
Is It OK To E-Mail?
- OK To E-Mail
Preferred Contact Method*

Domestic Abuse
Are you currently, or have you recently (past 6 months) been at risk of domestic abuse?*
- No
- Yes
DRCSAS are not domestic abuse specialists and the support we offer is specialised for survivors of sexual violence who are not at risk / haven’t experienced domestic abuse in the past six months.

SAFE / Fearl-Less / Victim Support are specialists in offering support to people who have experienced, or are experiencing, domestic abuse and are far better placed to support you at this time.

Sexual Offence
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.

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*
When it took place and how long for*
Relationship to perpetrator (e.g. male family member, female partner etc.)*
Do you have any contact with the perpetrator now?*

Support
Are you at risk (are there any concerns about your safety / risk of harm / safeguarding)?*
Are you currently receiving / waiting for support from any other service?*
Do you have any individual needs regarding an initial assessment (e.g. Location, days/times, language, mobility, disability access etc.)*

Domestic Abuse