Client Referral Form 
This form will enable you to refer yourself or someone you know into Harmless' Integrated Suicide Prevention Service. This covers self-harm, suicide crisis, and suicide bereavement support. We are dedicated to supporting those who need our help. 

Please provide as much detail as possible to ensure you access the most appropriate support. 

Everything that you tell us in this referral form is confidential. We will only break confidentiality if you or someone else is at immediate risk of harm.

Upon receiving your referral you can expect a response within 5 working days. If for any reason this does not happen then please do not hesitate to contact our service on 0115 8800 280 or nottingham@harmless.org.uk

Please note: If you are completing this for a friend or family member, please complete the information for them and not yourselves (i.e. their full name, their date of birth etc.). You can let us know information about yourself and your relationship to the person in the additional information section at the end. Thank you.

Sign in to Google to save your progress. Learn more
Please start by telling us some information about yourself.
Some questions are optional, and some questions are required. All of the required questions have red stars (*) next to them.
Full Name *
Date of Birth *
MM
/
DD
/
YYYY
Current Address  *
Current Postcode *
Mobile number  *
Email Address
Do we have consent to post a letter to your address? *
Do we have consent to leave a voicemail or text message? *
Gender: *
Pronouns *
Please select all pronouns that apply to you. 
Required
Ethnicity: *
Sexuality: *
Employment Status: *
Accommodation Status *
Name of GP Practice *
GP Address:
Phone Number for GP:
Details of any other mental health service that you are engaging with, have been referred to, or are on the waiting list for (please include name of service, address, and purpose of support).
GDPR - Consent

Key
1. Yes I consent to Harmless speaking to this organisation about my care, if needed.

2. No I do not consent to Harmless speaking to this organisation about my care

3. Not Applicatble - this organisation is not relevant to me
 *
Yes
No
N/A
School / College / University
GP
NHS Local Mental Health Team (LMHT)
Social Worker
NHS Crisis Team (CRHTT)
CAMHS
Social Prescriber
Other (please state)
If you have consented to us speaking to any of these services, please provide the full details of this service, including the name of the service, their
address, and the name of any allocated people (e.g.: specific social workers) who supports you.
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of Harmless CIC.

Does this form look suspicious? Report

Google Forms