Self Referral

Please note, our hours of service are Monday - Friday, 10am-3pm. We will respond to your enquiry as soon as we are able.
You can also contact us in the following ways:

Helpline: 01736 367539
Email: support@wcwaid.co.uk

Please be aware that this is not a crisis service.
If you need to speak to someone immediately, you can call the National Domestic Abuse Helpline on 0808 2000 247.
If you are at immediate risk of harm, call 999.

Name *

First

Last

Date of birth

Address Line 1

Town/City

Postcode

If that Town/City

Telephone *

Is it safe to call you? *--- Select Choice ---YesNo

Is it safe to text you? *--- Select Choice ---YesNo

Email *

Is it safe to email you? *--- Select Choice ---YesNo

Preferred method of contact *

• Phonecall
• Email
• Text

Do you have a time or day in the week (Monday-Friday, 10am-3pm) that is safest to contact you?

Do you have any communication needs, such as needing an interpreter? *--- Select Choice ---YesNo

If yes, please provide details

Do you have any accessiblity needs? *--- Select Choice ---YesNo

If yes, please provide details

Do you have any other needs that may be important for us to know, such as mental health concerns? *--- Select Choice ---YesNo

If yes, please provide details

Please give us a description of what you are seeking support for *

Please let us know what support you would like from WCWAid *

• Wellbeing/support calls
• Counselling
• Refuge
• Outreach
• Other

If other, please provide details

Consent *

• I give my explicit consent to the processing of my special category data in accordance with the Data Protection Act 2018.

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