Referral form

Referral Form
This service is for West Yorkshire residents over 18 only
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 in this instance or method used the most (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. *

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 (we will not contact A&E or MIU referrers in this case). In case of immediate risk of suicide the FRESH team will follow the Battle Scars procedures.

Referrer's service (in alphabetical order) *

Other referrer (if not on list above): *

Confirmation - REQUIRED *

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

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: referrals@battle-scars-self-harm.org.uk

Battle Scars Policies
Privacy Principles

Registered charity in England & Wales No 1177020
Registered charity in Scotland No SC052466

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

Funded by:

Leeds Compassionate City Awards Health Wellbeing category winner

Website by Battle Scars

Referral Form This service is for West Yorkshire residents over 18 onlyFor 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 West Yorkshire residents over 18 only
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)