What is your name?
* Required
Is this referral for you or a colleague?
* Required
Name of person being referred
* Required
Date of birth
* Required
Date
Address
* Required
Email address
* Required
Preferred contact number
* Required
You will be notified of your triage appointment by e-mail and text using the information above. Please let us know if this is a problem
Are you happy for us to leave a voicemail?
* Required** None Yes No
Alternative contact number
Are you happy for us to leave a voicemail on your alternative contact number?
** None Yes No
What is your job role / colleagues job role?
* Required
In which department or ward do you or your colleague work?
* Required
Which site(s) do you work on?
* Required
When we receive your referral, we'll be in touch to arrange an initial call to discuss your needs further. We'll aim to do this within 14 days...
Is your reason for accessing our service:
* RequiredWorked-related Non-work related Combination/unsure
Please outline the main issue you/ your colleague/ your employee would like support with
* Required
Is this referral time-sensitive for any of the following reasons:
* RequiredImminent work-related event (e.g., meeting with manager/HR, or returning to work) Significant risk of having to go off sick from work due to mental health Other Not time sensitive
What is the best time for you? Currently operating on a Mon-Fri basis with some early morning/ evening appointments available. Please list availability below
* Required
How did you come to know about the service?
* Required
Crisis Service information
We are not a crisis service. If at any point you feel you cannot keep yourself safe and need urgent support, please either
If you would like to talk to someone without judgement, feeling overwhelmed, worried, sad, or just need someone to listen, then the Samaritans offer support to NHS staff. The confidential support line is open 7am–11pm, seven days a week: 0800 069 6222 .
