Edinburgh Rape Crisis Centre

All fields marked as Required are required

Failed to send your application. Please check your application and try again.

Referral Info

Is the referral for yourself or for someone else? (Required)

It’s for me

I would like to help someone else get support

I am a family member / friend / partner looking for support for myself

I would like to refer my child (aged 12-18)

I would like to refer someone that I am working with

Organisation details

Organisation Name

Organisation Address

Organisation Telephone

Organisation Email

Are you the Parent / Partner / Family member or Friend of a survivor looking for support (up to 6 sessions) for yourself? (Required)

Yes

What age is the survivor you are supporting?

Is the survivor you are supporting already receiving support with ERCC?(Required)

Yes

Personal Details

Name

Gender(Required)

Woman

Man

Non-Binary

Gender queer

Intersex

Prefer not to say

Other

If other, please self describe;

Would you like us to use any specific pronouns?

Date of birth:

Age:

Women Only Time

We support all genders at ERCC, but in your sessions it will just be yourself and a female counselling support practitioner present. We ask survivors to arrive shortly before their session as we do not have a waiting room or any communal spaces for survivors.

Do you require a women-only time in the Centre which includes trans women? (Wednesdays 3pm-7pm or Thursdays 9am-1pm) (Required)

Yes

Do you require a women-only time for people born female? (Mondays 5-7pm or Fridays 9am-1pm)(Required)

Yes

Did the incident happen in the last 14 days?(Required)

Yes

Would you like Advocacy support?(Required)

Yes

Advocacy

Would you like support in relation to reporting to the police / involvement with the criminal justice system? ERCC neither encourages nor discourages survivors to report, but we have a dedicated Advocacy service that provides information and support for survivors who wish to do so.(Required)

Yes

These questions are not essential to make the referral, so if you feel it is too much to answer, please go to the next required question. Answering these questions would help us speed up the process of offering support.

If you can, please tell us which stage of the process you are at; Considering reporting to the police but haven’t yet Have started reporting to the police but still have statement to give Statements completed and police investigating Case has been handed from the police to the Procurator Fiscal A trial date has been set Interested in withdrawing from the process Interested in making a complaint Case has been dropped or concluded Unsure

If you have any upcoming meetings with the Police or Procurator Fiscal that you would like advocacy support around, please use this space to tell us when these are.

Additional Information

Are you part of any black and/or minority ethnic background? (Required)

Yes

Do you need an interpreter? (Required)

Yes

If Yes which language

Are you D/deaf or hard of hearing?(Required)

Yes

What do you need from us? e.g BSL interpreter or portable hearing loop?

Are you a student?(Required)

Yes

Student Info

Where are you Studying?(Required)

Edinburgh College

Edinburgh University

Heriot Watt University

Napier University

Queen Margaret University

Other

If Other please state

Emergency Contact

Is it ok for us to have details of an emergency contact for you?(Required)

Yes

Emergency Contact Name:

Emergency Contact telephone number:

GP Info

Is it ok for us to have contact details for your GP?(Required)

Yes

GP / Practice Name:

GP / Practice telephone number:

Additional Support

Do you have any additional support needs that we should know about?(Required)

Yes

Please tell us about your additional support need; Physical Support Needs Learning Needs / Difficulties Other

Please give details;

About your initial appointment

How would you prefer to receive support from ERCC? Face to face Remotely via video Remotely via phone

Face to Face

Are you able to access a face-to-face appointment in Edinburgh?(Required)

Yes

Are you able to access a face-to-face appointment in East Lothian?(Required)

Yes

Are you able to access a face-to-face appointment in Midlothian?(Required)

Yes

Video and Phone

Are you able to access a safe and private space for remote support by video or phone?(Required)

Yes

When are you available to attend an initial meeting with a support worker?

Day	Morning	Afternoon	Action
Monday
Tuesday
Wednesday
Thrusday
Friday

indicates required field

Women Only Times for Initial Meetings

When we provide support sessions we offer people the option of a time where only women will be present in the building.

The current times are:

Women only time which includes trans women - this in on Wednesdays 3-7pm and Thursdays 9am-1pm

Women only time for people who were born female - this in on Mondays 5-7pm and Fridays 9am-midday

This will be discussed with your worker in your initial meeting, along with any other access needs. However, please let us know if you would prefer to discuss this prior to the initial meeting.(Required)

Yes, I would like to speak to a worker about this first / now

No, I will not need this

Do you require childcare so you can attend an initial meeting?(Required)

Yes

Number of Children and their ages

Are you on a low income and / or receiving benefits?(Required)

Yes

Would travel costs be a barrier to you coming to face-to-face sessions?(Required)

Yes

Is there anything else you would like us to know?