Self reporting form

Please complete the form below:

Details of victim:


Special requirements:
Hearing impairment:
Support required:
Preferred contact:
Type of incident:


Do you know why this happened to you?
Do you know who they are?
Are they male or female?


If you are NOT the victim, please complete this section:


Have you reported to another agency?

Will you give us permission to speak to other agencies about your report?

We would like to use some of the following agencies to try to sort things out for you. Please tick appropriate: