Self referral form

The below form can be used by victims of road crashes to refer themselves to RoadPeace support services. On receipt of this form RoadPeace will reach out and conduct a needs assessment to discuss what services might be suitable for you. Services include 1-2-1 support, allocation of a befriender, attending regional meetings or taking part in remembrance events. 

Please only fill this form out for yourself, not for a friend or family member.