Self Referral Form

We will make first contact with the person being referred within 10 working days

Thank you for accessing the Synergy Essex self referral form.
If you are from an organisation please use our organisational referral form https://visia.cloud/app/form/essexorg

If you wish to contact us by telephone please call 0300 003 7777 and speak to one of our staff:

SOSRC Centre: press 1 for: Southend, Castle Point, Rochford
SERICC Centre: press 2 for: Thurrock, Basildon, Brentwood, Harlow, Epping
CARA Centre: press 3 for: Chelmsford, Colchester, Braintree, Uttlesford, Maldon, Tendring

Before you begin

REFERRALS FROM PROFESSIONALS OR AGENCIES MADE ON THE SELF REFERRAL FORM WILL NOT BE RESPONDED TO.
Click here to use the organisational referral form to refer someone you are supporting in a professional capacity.

We are a victim 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. Please 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 (tick box)*

This referral cannot be submitted unless the above information is confirmed. By ticking this box, you and the person being referred agree for checks to be made regarding their risk status. Essex Rape Crisis Partnership 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 Essex Rape Crisis Partnership. 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.

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

Main details

Please enter your name details

Client type

First Name

Last Name

Sex

Biological Sex registered at birth

Gender

Gender identity

Date of birth (dd/mm/yyyy)

Contact Details

If you do not reside in any of the listed districts, please contact us on 0300 0037777

District

Address Line 1

Address Line 2

Town

Postcode

Phone Number 1

Safe to leave a message?

Phone Number 2

Safe to leave a message?

Alternative Safe Contact Details

Additional Details

If the survivor/victim does not reside in any of the listed districts, please contact us on 0300 0037777

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

Please enter any comments below

By submitting this form you understand that your data is processed in accordance with our privacy notice