Aylesbury Vale Rape Crisis

Call us on 01296 392 468

Referral Form

This page contains our confidential referral form. You do not need an email address to use this form. The form is an alternative method of sending us information rather than using the postal system. The information is sent to AVRC and is exclusively used by AVRC to process your case.

Who should use this form?

Aylesbury Vale Rape Crisis is a women only service that provides support for women who have been affected by sexual assault, rape or child abuse recently or in the past.

If possible it is better if the woman contacts us directly but we acknowledge that the service users sometimes prefer that someone makes a referral on their behalf. To make a referral, please complete the form and return it to Aylesbury Vale Rape Crisis. If you have any questions please contact us by email or by telephone on 01296 392468

Referral Form
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Services





Personal Details

Address details (the following are optional)

How do you want us to contact you?





If we contact you using the phone





:

Safeguarding

Disabilities

Purpose of referral

Information about the referrer

Below this part of the form is an image with some text in it. Please enter the text you can see in the image into the box provided before submitting the form. You will know that the form has been successfully sent if you are taken to a Thank You page.

How to contact us

If possible, it is better if the woman contacts us directly but we acknowledge that survivors sometimes prefer that someone makes a referral on their behalf.

Referrals

To make a referral, please complete the form which is available in two formats, click on the following links (download referral form (PDF) or download referral form (MS Word) ) and return it to Aylesbury Vale Rape Crisis, or use the online form. If you have any questions please contact us by email or by telephone.

By phone

Our telephone number is 01296 392468 If you leave a message on our voice mail we will return your call as soon as possible and discretion is assured. Our phone number cannot be obtained by dialling 1471. Other organisations can signpost women to contact us.

By post

Write to the following address; PO Box 1058 Aylesbury Bucks HP20 9JZ

By email contact us form

If you contact us by email using our online form this is entered directly on the web. It does not leave a copy on the computer you are using. Please click here to use our contact form.

Using your email application

Please send an email to this address:support@avrc.org.uk

2016 © Aylesbury Vale Rape Crisis PO Box 1058, Aylesbury. Buckinghamshire, HP20 9JZ Registered Charity Number 1051608

Tel: 01296 392 468

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