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The survey will take approximately 5 minutes to complete.

Thank you for taking the time to complete these questions. Please note, you need to be a survivor (or family member where appropriate) to access Birchall Groups.

We ask you to be open and honest - none of your information is shared other than within the Birchall group co-ordination team.

Many thanks.

Please note: The Birchall Trust agrees to support all survivors of sexual violence unless they have a prevention order, are under investigation or have been convicted of any sexual offences. If you answer 'yes' to any of the next two questions, then please do not submit the form.

Have you ever been accused or convicted of a sexual crime, spent or un-spent?
Have you ever had, or do you currently have a Prevention Order of any nature?

For Birchall to manage the safety of all participants at our groups we need to ask some additional questions – answering yes to any of them does not necessarily mean you cannot attend our groups so please be honest.

Do you have any live court proceedings or are in Pre-Trial?
Do you have any involvement with any other services such as social services or mental health teams?
Do you have any issues with drugs including prescribed medication?
Do you have any issues with alcohol?
Have you ever had any suicidal thoughts?
Have you ever made plans to end your life or made an attempt on your life? Do you have any intent right now?
Do you have any worries about attending?
Are you able to commit & feedback on the group?

I confirm all the information I have given is true at the time of this assessment and I agree to update The Birchall Trust if anything changes.

Thanks for your submission, a member of the group co-ordination team will be in contact soon.

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