Skip to menu
Skip to content
Click
here
or press Escape
to leave this site now
The STAR Centre | Rape Crisis Ayrshire and Arran
Rape Crisis Scotland
helpline
08088 010302
Daily
5pm-midnight
Donate
Home
Referral forms
Self-Referral Form
Young Person Self-Referral form
Agency Referral Form
Support information
Support options
The Law on Sexual Offences in Scotland
The impact of rape on the survivor’s life
Coping with flashbacks
Understanding anxiety
Childhood Sexual Abuse and Its Impact
Other support services
Other support services
Donate
Home
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?
Anti-spam check:
In this section
Self-Referral Form
Young Person Self-Referral form
Agency Referral Form
Threads
BlueSky
LinkedIn
Instagram
@thestarcentre
