Request a service

You can request a service from us using the form below.

First though, please read the page Your Privacy - Using Our Services

When you have done so return to this page and click the box below to indicate that you have read and understood this information.

Our Privacy Agreement with you

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Request a service

Ready to get started? Fill out the form below.

Request a service

Request A Service

Date of birth
Address
Is it safe to call or text you on this number? *
Is it safe to email you at this address?
Preferred Contact Method (Tick all that apply) *
Do you have any children under the age of 18? (Tick all that apply)
Names and details of any children
Your current situation

To help us to meet your needs, please tell us some more about yourself

Sex / Gender - tick all that apply
Language - are you okay communicating in English?
Do you need an interpreter?
Which languages - tick all that apply
Help you may need to use services
Sexual Orientation

Your ethnicity

White:
Black:
Mixed / multi ethnic background
Asian

Tell us what types of support you are looking for - tick all that apply

Types of support

Because you chose " Wellbeing /Counselling support for myself", we have a few more questions for you

Have you used RISE Wellbeing, Counselling or Therapy before?

Please tell us a little bit about the reason for wanting Wellbeing or Counselling support – what is your day to day experience of living with the impact of domestic abuse.

Experiences

Please indicate the nature of the abuse you have experienced (tick all that apply)

Your Mental Health

Do you have a current mental health diagnosis?

Let us know what your diagnosis / mental health conditions are:

Medication

Are you currently taking any medication for a mental health condition?

Please tell us which medication(s) you are taking, and for which condition

Risks to your Wellbeing

Risks to your wellbeing

Please tick all that apply

Your GP

GPs Address
Other agencies or professionals

Are there any other agencies or professionals involved with yourself or your children?

What do you do that helps you to feel better, and who do you have around to support you?

Let us know anything else you think we should know

Let us know the best times to call you, Monday to Thursday 9.00 to 5.00

We are sorry but it looks like you are out of area for RISE services. We advise that you call the National Domestic Abuse Helpline for information about services in your area.

National Domestic Abuse Helpline: 0808 2000 247