Self referral form | Hertfordshire and West Essex Suicide Bereavement Service self referral form

Hertfordshire and West Essex Suicide Bereavement Service self referral form

If you are a young person and would like to refer yourself into the Hertfordshire and West Essex Suicide Bereavement Service, please complete the information below and one of our team will call you at a time that suits you best.

If you are a parent or professional wishing to refer a young person please use the other forms.

For parents : Parent/Carer Referral Form
For GPs and Professionals : Professional Referral Form

If you wish to retain a copy of the information you have provided in this referral please use the print option from your browser.

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Your First Name *

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Your Last Name *

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Your Date of Birth *

Address Line 1 *

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Address Line 2

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Address Line 3

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Town/City *

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Post Code *

GP Practice *

Mobile Number *

We will contact you via SMS text message to provide therapy appointments and reminders. Do you agree for us to contact you in this way?

Yes

Sometimes it can be difficult to get hold of people if we only have a mobile number. Please give us as much information as you can in the box below; so that we can get in touch quickly.

It would be helpful to have your email address, and an emergency contact email address or telephone number

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Please give us a brief description of what you would like us to help you with:

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I accept terms and conditions. *

If you are having difficulty with any of the questions or would rather speak to someone directly please call 01525 863924 during office hours (9 am to 5 pm).

Please note that CHUMS is not an Emergency Service and is not able to respond to this form urgently. Therefore, if there are any immediate risks identified or emergency care required please seek immediate advice from your GP/A&E.

Contact Telephone: 03300 581653

Contact Email: info@chums.uk.com