About You
Your Firstname
Required
Your Surname
Required
Your Date of Birth Required
Date
Your gender Required
Which place of learning do you attend?
Required
Your Address (if temporary or not permanent, please state)
Required
Your Phone Number
Required
Your Email Address
Required
About your Parents / Carers
We need to collect some contact details about one of your parents / carers.
Your Parent's / Carer's Firstname
Your Parent's / Carer's Surname
Your Parent's / Carer's Address
Your Parent's / Carer's Phone Number
Your Parent's / Carer's Email Address
Which GP Practice are you registered with?
Required
Is your parent / carer aware you are self referring? Required
If someone is helping you complete this form, please enter their name and contact details.
Contacting You
What is your preferred method of contact?
Can we telephone you? Required
Can we text you? Required
Can we email you? Required
Your worries and concerns
What are your main worries or concerns?
How long have you had these worries / concerns for?
Are you getting any help or support for these concerns / worries at all? Required
If yes, please give details (e.g from who and for how long).
Have you received any help or support for these worries / concerns before? Required
If yes, please give details (e.g from who and for how long).
Are you on any medication? Required
If yes, please give details (e.g from who and for how long).
Protecting You
Have any thoughts around harming yourself today? Required
If yes, please give details
If you require medical advice, call 111.
If you require urgent 24/7 mental health support call 0808 196 3002.
Do you think you may harm yourself in the future? Required
Have your hurt yourself in the past? Required
Do you think you might be hurt by someone else? Required
If yes, please contact First Response to inform them of this: 0800 131 3126
Any other information?
Please tell us about anything else that may be helpful for us to know.
What happens next?
Thank you for taking time to fill out this form, this is a huge step forward to getting yourself or a loved one the support they need.
We aim to review your information within a week.
Your health, wellbeing and safety is of top priority to us. You will be contacted as soon as posible.
Completing this will lead to your request being considered by emotional support services across South Staffordshire.
Please note: if you wish to send us additional supporting information (such as reports from other health or social care professionals), send them as email attachments to cafspa@mpft.nhs.uk , and be sure include your name, date of birth, and address within the email which will allow us match this correspondence to your referral.
Do you consent to us contacting you for feedback about your experience of self referral? Required
If you need help in the meantime contact your doctor, visit a NHS walk-in center or call NHS 111. If it is an emergency, dial 999 or visit A&E.
More information and places for support:
It's important to talk to friends, family members, and others that you trust about your feelings.
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