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Referral Form
This service is for
people over 18
living in
England
For more information, please click on the service logo
This is about the person we will call:
*
Indicates required field
Name
*
First
Last
Preferred pronoun (she/he/they/unknown)
*
Gender
*
Male
Female
Other (please use the box on the right)
Other gender
*
Age
*
Phone Number
*
This is the phone number we'll use. If it's a family member's instead of the person's above, please tell us (you can use the large box below)
First part of postcode
*
Date
*
Please select
*
This is for myself
I'm a professional referring the person above
Email - please provide us with your email address if you're filling in this form for yourself
*
Self-harm method used in this instance or method used the most (or thinking about using)
*
e.g. cutting, burning, overdosing, self-poisoning, ligature etc. This information will help us keep our workers safe.
Can we leave a voicemail if no answer?
*
Yes
No
If unsure, please select No
Any other information we need to know. For example, first time self-harmed, first time speaking about it, times not to ring, let the phone ring longer, try ringing more times, leave a gap between referral and ringing (please indicate how many days). Please let us know if the phone number belongs to anyone OTHER than the person above.
*
Ethnic background
This is for statistical purposes ONLY (the worker making the FRESH call will
not
have this information)
Asian or Asian British
*
Please select
Indian
Pakistani
Bangladeshi
Chinese
Any other Asian background
Black, Black British, Caribbean or African
*
Please select
Caribbean
African
Black British
Any other black background
Mixed or multiple ethnic groups
*
Please select
White and Black Caribbean
White and Black African
White and Asian
Any other mixed or multiple ethnic background
White
*
Please select
British: English, Northern Irish, Scottish, Welsh
Irish
Gypsy, Traveller, Roma
Any other White background
Other ethnic group
*
Please select
Arab
Any other ethnic group
Professional referrer's details - please ensure
all fields are completed
Referrer's name
*
First
Last
Referrer's email address
*
We will only contact the referrer if we have been unsuccessful in making contact or if we have serious concerns about this person. In case of immediate risk of suicide the FRESH team will follow the Battle Scars procedures.
Referrer's service (in alphabetical order)
*
Please select
A&E
Acute Liaison Psychiatric Service
Crisis service
GP surgery
Student Medical Practice
Third Sector Organisation
Other
Please give us more info such as the name of the organisation, type of service etc. :
*
Referrer's location
*
City, town, county etc.
& first part of postcode
*
Confirmation - REQUIRED
*
I have the above person's permission to refer them to FRESH
We will NOT proceed with this call unless you are referring with this person's permission
Click
here
if you'd like to provide more information about the project to the person you are referring
(printable version available)
Submit
If you are experiencing problems with this form please email us:
[email protected]
Home
About us
Our vision, mission & values
Definition of self-harm
ONWARD hire rooms
News
Our reports
Contact us
I self-harm
Virtual support groups UK 18+
F2F support groups Leeds adults
>
Daytime f2f group 18+
Evening f2f group 18+
Daytime f2f group 50+
Group posters & maps
16-25s support group Leeds
FRESH phone contact
Under 16's
Workbook for 10-17 year-olds
Facebook support group worldwide
Addiction programme
Order form - crisis cards etc.
I'm family/friend
Virtual F&F support group UK
F2F support group Leeds family
Dos & don'ts
FRESH phone service
I'm a professional
Training about self-harm or eating disorders
>
Self-harm training
Eating disorders training
Want to know more about Battle Scars?
Work with young people
FRESH phone service
Support for foster carers
Addiction workbook - PDF for professionals
How to write a self-harm policy
Order printed resources
Join the mailing list
Resources & more
Understanding s/h
Managing s/h
Self-awareness
For organisations
Videos & interviews
Blogs
Gallery
Support us
Become a Battle Scars trustee
Membership
Volunteer
LGBT+ service survey
Feedback about services
Onward Mental Health & Wellbeing Hub
>
Onward - the journey
Donations
Wristbands
Social media