Edinburgh Rape Crisis Centre

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

Myself

Organisation

Organisation details

Organisation Name

Organisation Address

Organisation Telephone

Organisation Email

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)

Yes

Personal Details

Name

Please select you Date of Birth. *You must be 12 years or older to submit this form.

Gender

Pronouns

Area

Address

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 Other please specify.

If we are unable to get you on the telephone number you provided can we send you an email?(Required)

Yes

Please provide a safe Telephone number we can use to contact you.

Email address

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 of portable hearing loop?

Is it safe for us to say we are calling from Rape Crisis when we call you?(Required)

Yes

If not what would you like us to say to you so you know who it is that is calling you? Please note: Our telephone number will come up withheld.

Can we send a text to this number?(Required)

Yes

Can we leave a voicemail on this number?(Required)

Yes

Has this incident happened within the last 14 days?(Required)

Yes

Where did you hear about us?

If Other please specify.

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)

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 you 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.

Would you able to access a safe and private space for remote support ie phone/video sessions?

Yes

Emergency contact name and phone number

Additional Information

Do you have any additional needs that we need to know about that would help us to support you?

Is there anything else you would like us to know?

Before submitting this referral, please check our privacy notice here https://www.ercc.scot/privacy-notice/ with regards to how we process your data.

I Agree

Are these details correct?

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Organisation details

Personal Details

Additional Information