Self Referral Form

First name *

Last name *

Email *

Phone number

Which of the following are safe forms of communication? *

Phone
Text
Email

Safe to leave a message?

Yes
No

Ethnicity *

Ethnicity other

We only support people of Black African, Caribbean and Mixed heritage who self-identify as women, girls and femmes.

Our team understands that the journey to safety and healing is unique to each individual, and we are dedicated to connecting you with the appropriate services tailored to your situation. These services include:

Immediate Crisis Support: Access to emergency shelters, safety planning, and crisis counselling.
Long-Term Assistance: Signposting to organisations specializing in legal aid, mental health support, housing, and more.
Culturally Sensitive Services: If you require support that addresses your specific cultural background or needs, we can help connect you to relevant resources.

If you or someone you know needs assistance, please visit our support groups and advice page or reach out using the contact information below, and our team will guide you through the next steps

You are not alone, and help is available.

We only support people of Black African, Caribbean and Mixed heritage who self-identify as women, girls and femmes.

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