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Self Referral Form

Thank you for accessing the Survivors West Yorkshire self referral form.
If you are from an organisation please use our organisational referral form https://visia.cloud/app/form/SurvivorsWestYorkshireOrg

Before you begin

Ben's Place is unable to offer support to those who are under investigation or have convictions for sexual offences.
Self-referring means you can contact us directly to access support.
This form is currently being developed and as a result we would ask you to contact us if you haven't heard from us after a couple of days in case there has been an issue with the form posting.


If you are a friend or family member you can make the referral for the survivor – however please note:.

  • We may only disclose information to the referrer about the client’s attendance and any issues discussed with the written consent of the client.
  • We will only accept referrals for male survivors who have agreed to connect and who are aware that the referral has been made.

There are just a few steps for you to take to help us offer the right support.

Please fill out the information and *click the 'Submit form' button. The form will be sent securely to Ben’s Place. When we have received it, we will contact the survivor via email and text to arrange a virtual understanding assessment. This will allow us together to explore information about Ben’s Place services. This is when you can ask any questions to help you decide if Bens Place is a good fit to support you.

Required fields are shown in red.

Main details

Biological Sex registered at birth
Gender identity
Contact Details

Additional Details

Are you are completing this form on behalf of someone else, if yes please provide your name and relationship to the above named person; in the comments box below. (Please note we can only accept this enquiry if the named person on this form is aware).