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Self Referral Form

Before you begin

REFERRALS FROM PROFESSIONALS OR AGENCIES MADE ON THE SELF REFERRAL FORM WILL NOT BE RESPONDED TO.

Click here to use the External Professionals Referral Form to refer someone you are supporting in a professional capacity.


We are a survivor focused organisation and as such we do not accept referrals for anyone who is subject (the suspect) to an ongoing police investigation for sexual, domestic or violent offences, or for anyone who may pose a risk of harm to others. I confirm that the person being referred does not pose a risk of harm to others, and is not known to Police regarding violent or sexual offences.

This referral cannot be submitted unless the above information is confirmed. By ticking this box, I / the person being referred agree for checks to be made regarding their risk status. Kent Sexual Assault and Abuse Service reserve the right to refuse the provision of services.

Self-referring means you can contact us directly to access support.

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

To self-refer, fill out the information and click the 'Submit form' button. The form will be sent securely to Kent Sexual Assault and Abuse Service. When we have received it one of our staff team will give you a call to arrange a first meeting. At this appointment you will have the opportunity to receive information about our services. This is when you can ask any questions to help you decide about the type of support you would like to receive.

Main details

Biological Sex registered at birth
Gender identity
Contact Details

Incident Details

Service Details
Please select one of the options below

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

Are you completing this form on behalf of someone else? (we can only accept referrals where the person is aware).