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Renewal Therapy Service - Referral Form
Please fill out this form as honestly and fully as you can. All personal data is stored securely and your confidentiality and privacy is our priority.

Please note, we are not an emergency service and only view referral forms in office hours.  If you are at immediate risk of harm or you are experiencing suicidal thoughts, please call 999 now.
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Name *
Date of Birth *
MM
/
DD
/
YYYY
Address *
Telephone *
Email Address *
Name of GP *
Address of GP *
GP Telephone Number *
What is the best way to contact you? *
If phone is your preferred method, can we leave a message if we don't get through?
Clear selection
What is the reason for seeking help?  (This is so we can connect you to the right person) *
Tick all that apply
Required
How long has this been going on? *
How is your day to day function affected? *
Have you any history of risks, including suicide, self-harm, substance misuse etc? *
Are you currently experiencing any suicidal thoughts, self harm or substance misuse issues? *
What previous help have you received? *
Required
Is anyone helping you at the moment? *
If yes / maybe, please give details
How did you hear about us? *
Submit
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