Referral form

Referral Form

Information about person being referred:

* Indicates required field

Name *

First

Last

Preferred pronoun *

Age *

Phone Number *

First part of postcode *

Time of presentation/seen by staff *

Self-harm method used in this instance *

Any other information we need to know. For example, this is the first time they've self-harmed, times not to ring, let the phone ring longer, try ringing more times, leave a day's gap between referral and ringing. *

Referrer details

Referrer's name *

First

Last

Referrer's email address *

Referrer's service *

Submit

If you are experiencing problems with this form please email us: referrals@battle-scars-self-harm.org.uk

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email: info@battle-scars-self-harm.org.uk
Tel (information & admin line only): 07410 380747 - office hours

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