Self Referral Form

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Rise works with women, children and those from the LGBTQ+ community who are survivors of domestic abuse.

If this applies to you, you can refer yourself to our services by filling in the referral form below.

Self Referral Form

We are sorry but it looks like you are out of area for RISE services, as we are only funded to support people who live in Brighton and Hove. We advise that you call the National Domestic Abuse Helpline for information about services in your area.

National Domestic Abuse Helpline:

0808 2000 247

Date of birth
Address
Is it safe to call, text, or leave a voicemail 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)

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
Your current situation
Have you experienced Economic Abuse? This might include having debts, being unable to access your own money, or being unable to financially support yourself because of the abuse. *
Have you ever been affected by Gambling? *

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

Types of support

*Please note, the waitlist for our therapy service is currently closed until further notice. We are therefore not accepting referrals to our therapy service at this time*