Self Referral

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.

    Please note we are only able to currently accept referrals from Furness & South Cumbria
    After filling out the Self Referral From below, you will initially be contacted by one of our trained counselors via Email. If you prefer to be contacted another way please specify.

    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 your waiting list time. If you tick yes we will be in contact with further information. Otherwise you will be added to the normal SAFA waiting list.
    Do you want to contribute financially to your counselling sessions in order to reduce your waiting list time?
    YesNo

    Personal 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 you at the above address?
    Email Address
    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
    How did you hear about SAFA?

    Self Referral Reason

    What do you see as your method of self-harm?
    For how long have you been doing this?
    Have you 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
    Anti-depressants
    Please specify
    Anxiolytics - Hypnotics

    (minor tranquilizers)

    Please specify
    Other
    Please specify

    Personal Consent

    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 Cup.
    To clear data imputed into this form please press the clear button.

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