Professional Referral

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.

    Please note we are only able to currently accept referrals from Furness & South Cumbria
    Professional body referrals, please continue and complete below.

    Financial Contribution

    Each counselling session has a full cost of £85. We are inviting contributions of £35 per session payable at the beginning of each session which will reduce client waiting list time. If you tick yes, we will contact your client with further information.
    Does your client want to contribute financially to their counselling sessions in order to reduce their waiting list time?
    YesNo
    How did you hear about SAFA?

    Client Details

    First Name
    Last Name
    Date of Birth
    Gender Identity
    Other
    Address Line 1
    Address Line 2
    Town or City
    County
    Post Code
    Residential situation (living alone, with partner, flat share)
    Can we contact your client at the above address?
    Email Address
    Home Phone Number
    Can we contact you 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
    Please provide details

    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
    Please prove you are human by selecting the Key.
    To clear data imputed into this form please press the clear button.

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