Self referral form

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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.

Self referral form

Please complete this form as fully and accurately as possible. We understand that it can be difficult to share details, so only provide us with what you are comfortable sharing

Your details

Name(Required)

Preferred methods of contact(Required)

Phone

Post

Email(Required)

Phone(Required)

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Address

Date of birth (You must be 18 or over to receive support from RoadPeace)(Required)

Please indicate any days and times that are unsuitable to receive contact

About the crash - victim and crash details

I am...(Required)

Victim's name(Required)

Victim's age(Required)

Victim's date of birth

Date of death

Date of collision

Police force investigating

Location of collision

Collision circumstances

Please only put as much information as you feel able to share

Any other information/comments

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Self referral form

Self referral form

Your details

About the crash - victim and crash details