Book a surgery appointment

In this page, surgery hosts and SWRC workers can book surgery appointments on behalf of survivors.

Please complete the two steps below.

Step 1 - Select and book a date and time
(this part should be completed using your name and your group/centre's email address. You will only be asked to enter the survivor's contact details in Step 2 of this process, which can be found below the calendar).

Step 2 - Fill out the form using the survivor's details

Fields marked with a * are required.

About the surgery appointment

Appointment date: *

Appointment time: *

Appointment will take place over: *

About the survivor

Survivor's name: *

Survivor's email address: *

Survivor's phone number: *

Is it safe to leave a voice message? *

Is it safe to leave a text message? *

Requires language interpreter? *

If yes, please indicate language:

Do you have any accessibility needs? *

If yes, please indicate your needs here:

About the case

Brief description of legal issue: *

Types of Gender-Based Violence the issue relates to (tick all that apply):

Domestic abuse Rape/Sexual abuse Stalking Sexual harassment Online abuse Forced marriage So-called "Honour-based violence" FGM Other (please specify below)

Any immediate safety concerns? *

If 'Yes', please explain:

Survivor has support in place? (If answer is 'No', offer details of national and local support services) *

Referring organisation/agency

Name of worker making the booking: *

Email address of worker making the booking: *

Consent confirmation: *

I confirm that I have entered the above information correctly and that I have the woman's consent to share this information with SWRC.

I have read the Privacy Policy and understand that I am responsible for the information I have entered in this form.

Complete our anti-spam check:

Helpline

08088 010 789

Our daytime helpline is currently available:

Mondays between 10AM and 12:30PM
Wednesdays between 10AM and 1PM

Our evening helpline, staffed by pro-bono solicitors who can provide initial advice, is currently available:

Tuesdays between 6PM and 8PM

For up-to-date availability including any upcoming closures, please click here.