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The STAR Centre | Rape Crisis Ayrshire and Arran
Rape Crisis Scotland
helpline
08088 010302
Daily
5pm-midnight
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Referral forms
Self-Referral Form
Self-Referral Form
To complete a self-referral, please fill in the form below.
Fields marked with a
*
are required.
Your name:
*
Your date of birth:
*
Your phone number:
*
Your email address (if you would like us to email you):
Is it safe to phone you on the above number?
*
--- Please choose an answer ---
Yes
No
If we call you on this number, is it safe for us to identify ourselves?
*
--- Please choose an answer ---
Yes
No
N/A
If you cannot answer our call, is it safe to leave a voicemail or message?
*
--- Please choose an answer ---
Yes
No
N/A
Is it safe for us to text you?
*
--- Please choose an answer ---
Yes
No
How do you prefer us to contact you?
*
--- Please choose an answer ---
Phone call
Email
Text
Have you reported the incident/incidents to the police?
*
--- Please choose an answer ---
Yes
No
Any other information we should know?
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