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Self Referral Form

RSACC has made the difficult decision to temporarily stop accepting any new adult referrals to our counselling service. While we regret having to make this decision, we do not feel we can fairly add new referrals to our waiting list until funding is secured to confidently provide the service beyond March 2026. Please look at our website for further information around the waiting list closure for our adult counselling service and for what support is available. We hope to be in touch with a further update in due course. In the meantime, if you require more information about our other services or alternative provisions, please get in touch with our team who are here for both you, and your clients. Please note we are still accepting counselling referrals for anyone who is 18 and under, our ISVA service and any of the Groups
If you are a parent, carer or friend filling in this form on behalf of the person you are referring, please use the Organisation Referral Form. And use the Third Party option in Referring Organisation Category. And if you attend Durham University please let us know.

Before you begin completing this online form please note we are happy to answer any questions you may have however, we do not provide a crisis service. In case of an Emergency please call 999.


IMPORTANT PLEASE READ: Before submitting a referral please pay attention to the Information within the Service Details section or take a look at our website ‘Get Help’ tab (all the services we provide), this will help you when choosing what service is right for you. If you are unsure about which service to refer to, then please feel free to contact the office on 01325 354 119 or email: info@rsacc-thecentre.org.uk.


We offer free, safe support to anyone over 13 who has experienced any form of sexual violence at any time in their lives.

We can accept referrals from clients who live, work or are accessing education from the following postcode areas: DL1 - DL17, DH1 - DH9, SR7 - SR8, TS21, TS27 - TS29, NE16.

Please note for Durham police referrals please do not use the form below and follow the correct referral pathway.

Please complete the below form with as much information as possible.

Required fields are shown in red

Main Details
Please enter your name details

Biological Sex registered at birth
Gender identity
Service Details
Please select one of the options below

Explanation of services (Click here to show/hide details)
Client Contact Details

Additional Details

Please tick box to show consent given for referral to support services.