Make a referral - Support Hub for Victims of Terrorism

Start your referral

Use this form to make a referral to the Support Hub for Victims and Survivors of Terrorism. It allows you to tell us how best to support your needs, or the needs of the person you’re referring. We will be in touch as soon as possible, usually within 2 working days. If you are making a referral on behalf of someone else and they have consented to being contacted, we will contact them in the first instance.

How can we help you?(Required)

I am referring myself to the Support Hub for Victims and Survivors of Terrorism.

I am referring a friend or family member.

I am a professional from an organisation referring someone I support.

Which terror incident does this relate to?(Required)

Please tell us which incident this relates to. You do not need to go into detail about your experience.

Your personal details

Your first name(Required)

Your surname(Required)

Date of birth(Required)

Use the calendar to select your date of birth, or type if preferred.

Pronouns

For example: she/her, he/him, they/them, she/they, he/they, she/him

Preferred language(Required)

Other language(Required)

Your organisation's name(Required)

Your job title(Required)

Your contact information

We need this information to update you on the progress of your referral and what happens next

Phone number(Required)

Email(Required)

Preferred contact method(Required)

Telephone call

Preferred contact time

Help us understand when is best to contact you

From

Until

Please let us know if there is anything we can do to make things more accessible or comfortable when we contact you

Examples: Speak slowly, I'm hard of hearing, I need a language interpreter, I need a BSL interpreter, etc.

Victim-survivor's personal details

Survivor's first name(Required)

Survivor's surname(Required)

Date of birth(Required)

Use the calendar to select their date of birth, or type if preferred.

Pronouns

For example: she/her, he/him, they/them, she/they, he/they, she/him

Preferred language(Required)

Other language(Required)

Your location

Which area of the UK are you in?(Required)

Which region are you in?(Required)

Select the region in England you are in.

Which region are you in?(Required)

Select the region in Wales you are in.

Which region are you in?(Required)

Select the region in Scotland you are in.

Victim-survivor's location

Which area of the UK is the victim-survivor in?(Required)

Which region are they in?(Required)

Select the region in England they are in.

Which region are they in?(Required)

Select the region in Wales they are in.

Which region are they in?(Required)

Select the region in Scotland they are in.

Has the victim-survivor consented to us contacting them directly?(Required)

Yes

Victim-survivor's contact details

We need this information to update the victim-survivor on the progress of their referral and what happens next.

Phone number(Required)

Email(Required)

Preferred contact method(Required)

Phone

Preferred contact time

Help us understand when is best to contact them

From

Until

Please let us know any access needs we need to be aware of when we contact the victim-survivor

Where did you learn about the Support Hub?

How did you hear about us?

How did you hear about us (other)

Submit referral

By submitting this form, you confirm that you have read and understood our Privacy Policy We will process the personal data provided for the purpose of delivering the Support Hub for Victims and Survivors of Terrorism. This may include personal data about you and/or another individual. Processing is carried out on the legal basis of our legitimate interests, in accordance with data protection law.

Where you are referring someone else, you confirm that you are authorised to share their information for this purpose.