Refer yourself

This form is for individuals who would like to request support for themselves. You can complete it in your own time, and a member of our team will contact you safely to discuss the next steps.

We treat all information with care and confidentiality. If completing this form is not safe, please use our advice line instead.

I need support

* Required

Name*

First

Last

Your date of birth*

What is your sex?*

What is your gender identity?*

What is your ethnicity?*

Phone*

Please enter a phone number that it is safe for us to call

When is it safe to call this phone?*

Please enter a phone number that it is safe for us to call

Can a message be left on this phone?*

Yes, voicemails can be left on this number

No, please don't leave a voicemail on this number

Email address*

Untitled

Option 1

Option 2

Option 3

Address. Please include your postcode.*

Are you living with an abusive family member?*

Yes

To ensure your message reaches the correct team, please select your area*

Choose your area from the list

Details of family members in your household.*

Please provide their full name, their relationship to you, their date of birth and their gender.

Please tell us a bit about what's currently (last 6-8 weeks) been happening*

Name of the alleged perpetrator (if you know it)

First

Last

Date of birth of the alleged perpetrator

Address of alleged perpetrator, if known

Relationship of the alleged perpetrator to you*

What support do you need?*

How did you hear about us?*

Are you human?*

Email address*

The help we offer

We provide a range of flexible and accessible services across Hampshire, Portsmouth and Southampton including refuge, community support and support around healthy relationships and challenging abusive behaviour.