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 one-to-one support, allocation of a befriender, attending regional meetings or taking part in remembrance events. We will endeavour to contact you within 5 working days.

Please only fill this form out for yourself, not for a friend or family member. If you are unable to complete the form or prefer, call 0800 160 1069 or email helpline@roadpeace.org.