ARCH Teesside

Self Referral Form

Before you begin

ARCH provide a non-judgemental, confidential service and we try to make referring to us as easy as we can.

The form will be sent via a secure connection (SSL), which is encoded and goes straight into our database, accessed by ARCH staff only.

Before submitting a referral please read the service criteria/explanation within the service details section below; this will help you to decide which service or services will be of most benefit to you.

When we have received your referral our referrals team will give you a call to complete the process with you; this will be approximately within 4 working days of us receiving the form.

We do not provide a crisis service. If you are in immediate danger, please dial 999. You can also call our office on 01642 822331.


Please read the following before continuing

ARCH Teesside are a victim-focused organisation, and as such, we are unable to support anyone who is subject (the suspect) to an ongoing or previous police investigation for sexual, domestic, or violent offences, or anyone who may pose a risk of harm to others.

If this applies to you, please consider contacting:

ARCH Teesside Counselling Service provides therapeutic support for anyone in Middlesbrough, Stockton and Hartlepool who has experienced rape or any form of sexual abuse at any time in their lives and is struggling to cope with their feelings and emotions in relation to these experiences. We also offer support to Men and Boys from Redcar and Cleveland.

Therapy can be hard work and extremely challenging, especially in the early days. It is therefore important to consider whether ARCH is right for your needs before making a referral. For example, we are unable to provide emergency crisis support or work with complex or severe mental health issues. Please speak to our referrals team on (01642) 822335 to discuss your needs if you are unsure.

We are unable to accept referrals for individuals who:

  • Are currently experiencing a mental health crisis
  • Are actively suicidal or have attempted suicide within the last 3 months
  • Are currently an inpatient under Secondary Care Mental Health Services
  • Have had multiple admissions or discharges from Secondary Care Mental Health Services within the past 12 months.

If you are struggling with issues relating to substance misuse, consideration should be given to specialist services, in your best interests.


Our services

Advocacy (ISVA) – our Independent Sexual Violence Advisers offer specialist, trauma-informed emotional and practical support if you have reported to the police, or are considering doing so, including support throughout the police investigation and, if the case gets to court, beyond.

Counselling – trauma-informed one-to-one counselling to talk about how rape or sexual violence has affected you, at any point in your life.

To self-refer, fill out the information and click the “Submit” button at the end of the form.

ARCH aims to offer a confidential service. However, if we are concerned about your welfare, or the welfare of others, then we may need to share information with appropriate external agencies. Please tick the box below to give your consent for us to keep this data.

I consent  

Required fields are shown in red. You will not be able to submit the form if you do not complete the mandatory fields and tick the above tick box relating to consent.

Main details
Please enter your name details

Gender identity
Service Details
Please read the service criteria above, then indicate which service(s) you would like. Please select at least one.

Contact Details
If you do not reside in any of the listed districts, please contact us on 01642 822331

Additional Details
If the survivor/victim does not reside in any of the listed districts, please contact us on 01642 822331

If you are completing this form on behalf of someone else, please provide your name, and relationship to the person being referred in the comments box below. Please note we can only accept this referral if the person being referred is aware, and consents to the referral being made.

I confirm that I do not pose a risk of harm to others and am not known to the police regarding violent or sexual offences.

By ticking this box, I agree for checks to be made regarding my risk status.

ARCH Teesside reserve the right to refuse referrals and the provision of services. Contact 01642 822335 for more information. This referral cannot be submitted unless the above information is confirmed.