Referral Form - Professional/Parent/Carer  
Hi there,

Thank you for referring an individual (aged 16+) to We Are Resurface.

Please visit our website (www.weareresurface.com) to find out more about what we offer.

The next step is for you to complete the form below and we'll be in touch once we have reviewed your referral.

All the information you provide on this form is kept confidential and used solely for our records, unless authorized by you. However, in extreme situations such as threats to life, terrorism, or fraud, confidentiality may be breached.

We are not a crisis service. If you are concerned about the immediate safety of you or someone else then call 999 for emergency services or visit your local A&E.

If you are safe and need someone to talk to for urgent support in a crisis, you can get it here:

Call NHS 111 – 'connections' mental health support 24/7 help in crisis
Call Samaritans on 116 123 or 08457 909090 www.samaritans.org
Text “SHOUT” to 85258 www.giveusashout.org
If you are under 19, you can also call 0800 1111 to talk to Childline. 
The number will not appear on your phone bill.
Call Papyrus on 0800 0684141 - a national suicide prevention charity offering support and guidance if you or someone you know is struggling to cope

Other Helpful support organisations:

Saneline – 0300 304 7000 (430pm – 1030pm) or www.sane.org.uk
Alcoholics Anonymous - 0800 9177 650 or help@aamail.org
The Mix – Under 25s www.themix.org.uk 0808 808 4994
Switchboard – LGBT chris@switchboard.lgbt 0300 330 0630 (10am – 10pm)
CALM –www.thecalmzone.net 0800 585858 (5pm – Midnight) 

The Retreat (Dorset Mental Health Forum)- The Retreat is a safe and welcoming environment for anyone over 18 years of age, based in Dorset and who have self-identified their crisis and want to access support. You can find them at Hahnemann House, Hahnemann Road, Bournemouth, BH2 5JW open daily (16:30-00:00). You can drop in – no appointment needed.

Paragon: Dorset’s Domestic Abuse Helpline 0800 032 5204 or for Bournemouth & Poole outreach team 01202 547 755.

Domestic Abuse Refuges: Call 24 hour helplines. Dorset- 0800 032 5204. Bourmeouth- 01202 547 755. Poole- 01202 710 777 (can take men, those experiencing honour based violence and forced marriage).

Hub of Hope: To find mental health and crisis services in your local area, from all across the UK, simply type your postcode into the search bar onhttps://hubofhope.co.uk/.

No panic: Urgent support for those struggling with panic attacks as well as anxiety disorders. No Panic's  helpline is open 365 days of the year 10am-10pm, just call 0300 772 9844. They can support with 'in the moment' breathing and relaxation techniques and more:  https://nopanic.org.uk/ 

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Please confirm you have received consent from the individual before submitting their details via this referral form: 
*
Has the parent/carer given consent for the young person to join Resurface?
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Please state which programme you are referring for: *
First and last name of referrer: *
Contact number of referrer:
Email address of referrer: *
Role / relationship to the person you are referring
*
Organisation name and address (if professional referring only)

If you are a parent/carer, please write N/A
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How did you hear about Resurface? *
Would you like to speak to us before we contact the person you are referring?
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First and last name of person you are referring: *
Email address of person you are referring: *
Contact number of person you are referring:
Date of Birth: *
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DD
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YYYY
What gender do they identify as?
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Please share why you believe Resurface Therapy could be helpful for the individual you are referring:
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Referral Confirmation

Please sign to confirm you give permission for Resurface to process the personal data given on this form. You can find out how we use data from our data protection policy available on request via info@weareresurface.com
Please type your name and date: *
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