Referral form

Gender

Age

Ethnicity

Contact details

Phone number

Are You Happy For An Emotional Support Volunteer To Leave A Voicemail/Message At Any Time?

Preferred Time For Contact:

Clients Preferred Language:

I Would Like Support/Counselling For:

Medical/Mental Health History:(please provide as much detail as possible)

Drug History: (please include prescribed drugs and any other drugs)

Name of the GP
GP Surgery/Practice

Address

Contact number

Thank you for taking the time to complete this form.

All referral forms are screened and referred to the appropriate team. The support you're offered will depend on the problems you're experiencing and how severe they are. Someone from the Supporting Humanity team will get in touch to ask about the problems you're having.

This service does not provide assistance or support if you need urgent help in a crisis, If you or a loved one are experiencing a mental health crisis, please call a local NHS mental health helpline for 24-hour advice and support by finding your local service by following the link below:
https://www.nhs.uk/service-search/mental-health/find-an-urgent-mental-health-helpline

or If someone's life is at risk or they cannot be kept safe, call 999 or go to A&E.