Self reporting form


Please complete the form below.

Details of victim
Gender
Special requirements
Hearing impairment
Support required
Preferred contact
Type of incident
About the incident

Date of incident




Do you know why this happened to you?
About the person who did this
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?
Permission

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.

Police
Citizens Advice
Landlord
Local Authority
Other