Self 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 referring through a professional body, you must use this Professional Referral Form. Self referrals please complete below.

After filling out the Self Referral From below, you will initially be contacted by one of our trained counsellors via Email. If you prefer to be contacted another way please specify.

Personal Details

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

Self Referral Reason

What do you see as your method of self-harm?
For how long have you been doing this?
Have you done any self harmed before this current episode?
YesNo
Would you want to give us more information on this form?
YesNo
Please provide additional information

Characters Remaining: 500

GP Details

Please provide details of your Doctor (if known)

GP Name
GP Practice Name
GP Practice Address

Current Support

Please provide details of your Counsellor/ Worker if applicable

Do you have a Mental Health Counsellor or Worker?
YesNo
Counsellor Contact Details
Please provide your current support information
Are you seeing any other Therapist, Psychologist or Psychiatrist?
Please provide details

Medical History

Please provide Medical History if applicable

Do you have any Medical Problems that we should be aware of?
YesNo
Please provide Medical Problem details
Are you currently taking any medication?
YesNo
Please tick the type of medication

Anti-psychotics

(neuroleptics/major tranquilizers)

Please specify below


Anti-depressants

Please specify below


Anxiolytics
/Hypnotics

(minor tranquilizers)

Please specify below


Other

Please specify below


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