Referral form

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 *

Other gender *

Age *

Phone Number *

First part of postcode *

Date *

Please select *

Email - please provide us with your email address if you're filling in this form for yourself *

Self-harm method used (or thinking about using) *

Can we leave a voicemail if no answer? *

Yes 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. *

Best time to ring you - we'll do our best to follow these instructions. The call will come from a private number, please answer it even if it's to reschedule the call *

10am - 2pm 2pm - 6pm either

Any other information about best days and times *

Ethnic background
This is for statistical purposes ONLY (the worker making the FRESH call will not have this information)

Asian or Asian British *

Black, Black British, Caribbean or African *

Mixed or multiple ethnic groups *

White *

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 give us more info such as the name of the organisation, type of service etc. : *

Referrer's location *

& first part of postcode *

Confirmation - REQUIRED *

I have the above person's permission to refer them to FRESH

Submit

If you are experiencing problems with this form please email us: [email protected]

Registered charity in England & Wales No 1177020
Registered charity in Scotland No SC052466
Website designed by Battle Scars

Battle Scars
Onward Mental Health & Wellbeing Hub
Onward House
Millshaw Park Way
Leeds LS11 0LS
email: [email protected]
for enquiries about room hire/rental: [email protected]
Tel (information & admin line only): 07410 380747 - office hours

Battle Scars Policies
Privacy Principles

Funded by:

Leeds Compassionate City Awards Health Wellbeing category winner

Referral Form This service is for people over 18 living in England For more information, please click on the service logo

Ethnic backgroundThis is for statistical purposes ONLY (the worker making the FRESH call will not have this information)

Referral Form
This service is for people over 18 living in England
For more information, please click on the service logo

Ethnic background
This is for statistical purposes ONLY (the worker making the FRESH call will not have this information)