Self-referral

Your details
Name

Date of Birth

Age

Gender

Preferred pronouns

Address

Contact Telephone Number

Email Address

Reason for referral - please tick all that apply
Self harmSuicidal thoughtsSuicide attemptEmotional or psychological distressOther (please specify)

Other:

How long have you been feeling this way?

Have you felt this way or similar previously?
Please provide details and any diagnosis or treatment/support received:

Are you experiencing any of the following symptoms (tick or describe as appropriate)
AnxietyPanic symptomsLow confidence/self esteemEmotional regulation difficultiesOther (please specify)

Other or further details:

Background information
Include any relevant history such as family context, education, work, housing, significant life events, or previous support:

Current Support
Are you currently receiving any support from other services or on a waiting list? If yes please provide details of services, named workers and contact information if known:

Risk and safeguarding information
Please indicate any known risk to self or others, safeguarding concerns or relevant behavioural information: No known risksSelf-harmSuicidal thoughtsAggression towards othersOther please specify

Other:

Medical Information
Any diagnosed conditions (e.g. anxiety disorders, ASD, ADHD)

Medication (if applicable)

Allergies or health condition

I consent to this information being shared with professionals within Humber Wellbeing Services and to be contacted as appropriate.