Professional Referral Form

In a emergency, please contact your own GP. The Cumbria Health On Call team (CHOC) are also available out of hours on 111. The Samaritans are available 24 hours a day on 116 123.

*SAFA is GDPR compliant. Once the below form is submitted to us, the forms data is encrypted and automatically password protected. Only a team member from SAFA can access the data provided.

Due to confidentiality, Please make sure when referring you use the correct form, either Self or Professional.

If you are self referring, you must use this Self Referral Form. Professional body referrals, please continue and complete below.

Client Details

First Name
Last Name
Date of Birth
Gender Identity
MaleFemaleOther
Other
Address Line 1
Address Line 2
Town/City
County
Post Code
Residential situation (living alone, with partner, flat share)
Can we contact your client at the above address?
YesNo
Email
Home Phone Number
Can we contact your client on this phone number?
YesNo
Mobile Number
Can we contact your client on this mobile number?
YesNo
Does your client have a disability?
YesNo
Disability details
Is your client currently involved in any legal proceedings?
YesNo

Referral Reason

What is the clients method of self-harm?
How long has your client been doing this?
Has your client self harmed prior to this episode?
YesNo
Do you have more of the clients Self Harm information you could provide us with?
YesNo
Self Harm additional information

Characters Remaining: 500

Is the person substance abusing?
YesNo
Please list substance abused/mis-used, age abuse started, frequency of abuse, whether injecting, history of overdoses

Characters Remaining: 500


In your opinion, is the person a risk to themselves or to others?
Risk NoneMildModerateSevere
Suicide NoneMildModerateSevere
Self-Harm NoneMildModerateSevere
Harm to others NoneMildModerateSevere

Can you provide any additional information
YesNo
Please provide additional information

Characters Remaining: 500

If a risk assessment has been completed, could you please upload the document.

Referrer Details

The following fields are * required. When inputting your name, this acts as a signature. By giving SAFA your signuture, it will give consent for information to be shared between yourself and SAFA, when it is deemed in the best interest of your client.

*Referrer Name
*Referrer Organisation
*Organisation Address
*Referrer Telephone
*Referrer Email
*Date

By submitting this form I accept the information provided will be held by SAFA. This information will be kept confidential, however there are some extreme situations where SAFA may be obliged to share information.

Please note that referrals are usually reviewed by a counsellor within two working days (Monday-Friday)

By ticking this box, I confirm my consent as stated above