All fields marked as Required are required

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Are you referring yourself or are you an organisation referring an individual to us? (Required)

Organisation details

Do you have permission from the person being referred to contact us? *Edinburgh Rape Crisis will never contact a survivor who has not given their consent to have their details passed on to us.(Required)

Personal Details

Our East Lothian and Midlothian outreach support services for adults are currently closed to new referrals. All our services are still open to survivors who have experienced a rape or sexual assault within the last 14 days
Our advocacy service is currently open for all survivors living in East Lothian and Midlothian regardless of when the incident happened

If we are unable to get you on the telephone number you provided can we send you an email?(Required)
Are you part of any black and/or minority ethnic background? (Required)
Do you need an interpreter? (Required)
Are you D/deaf or hard of hearing?(Required)
Is it safe for us to say we are calling from Rape Crisis when we call you?(Required)
Can we send a text to this number?(Required)
Can we leave a voicemail on this number?(Required)
Has this incident happened within the last 14 days?(Required)

Our Advocacy service is currently closed to new referrals

Would you like support in relation to reporting to the police/ involvement with the criminal justice process? We neither encourage or discourage survivors to report, but we have a dedicated advocacy service that provides information and support for survivors who wish to do so. (Required)

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 you support.

If you can, please tell us which stage of the process you are at
Would you able to access a safe and private space for remote support ie phone/video sessions?

Additional Information

Before submitting this referral, please check our privacy notice here with regards to how we process your data.