Web Referral Form
Nexus NI offer counselling to survivors of sexual abuse, rape and sexual assault. If you would like counselling please complete this form and we will contact you. We will keep your details confidential (please refer to our website for our policy on confidentiality)
Date of Birth
Allow contact by phone/mobile:* (required)
OK to leave messages?* (required)
If we ring you back our number will display as private number.
OK to send text reminders for appointments?
Do you consider that you have any physical disability that could affect counselling?
What is your preferred Location for Counselling?
What times are you available to attend counselling?
Have you attended NEXUS before?
Who told you about Nexus?
WebThe RowanGPHealth professionalPoliceFamily/FriendsContact NILifelineSocial workerWomen’s AidNSPCC
Other (please specify)
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