Please only complete this form if you are making a referral for Counselling services. 

For general enquiries please use the form on the Contact Us page.

Please ask permission if you are submitting this form on behalf of someone else, and make sure they have read the statement below.

Guidance notes:

  • dual experience means that you are a Survivor of sexual violence who has also perpetrated sexual offences
  • method of support can be: face to face, phone call or video call


By submitting this form to Survive, I consent to my data being used by Survive for the purpose of providing me with counselling and support services.  I understand that my personal data will be stored securely and will not be shared with third parties without my consent.

For full details of how we look after your data please refer to Survive’s confidentiality and data protection policy on our website here or ask for a copy.



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