Referral form

Visitor introductions – Please complete as much as possible or appropriate.
(Please note that compulsory fields are marked by a red asterisk.)

Name of person making referral *

Email address of person making referral*

Name of organisation making the introduction*

Postcode of organisation making referral*

Phone number of person/organisation making introduction*

Name of suicidal person being introduced *

Forename*

Surname

Telephone number of person being introduced*

On a scale of 1 to 10, 10 being the highest, how suicidal would you estimate this person feels? *

On a scale of 1 to 10, 10 being the highest, how likely to kill themselves would you estimate this person is? *

Please note that while The Listening Place offers ongoing support for people in times of suicidal crisis, if you feel you need immediate support please use emergency services (A&E/999).

Gender of person being introduced

Date of birth of person being introduced

Address of person being introduced

Address line 1:

Address line 2:

Address line 3:

Address line 4:

Postcode (or if the person who is being referred does not have a fixed address, please write "no postcode") *

Email address of person being introduced

General presenting reason for appointment at The Listening Place *

Nature of suicidal thoughts *

Visitor expectations of The Listening Place *

Confirmation *

I confirm that this information is correct, and that the person whose information is being submitted is aware that they are being referred for support with The Listening Place and has consented to this information being given to us. I understand that The Listening Place’s volunteers offer listening by appointment only, and that they will get in contact with this individual as soon as possible using the contact details provided. However, if there is a need for immediate or urgent help, I will also consider a referral to 999, emergency services, or an NHS medical or mental health provider. For more information on our Privacy Policy please Click here.

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Referral form

Visitor introductions – Please complete as much as possible or appropriate.
(Please note that compulsory fields are marked by a red asterisk.)

Name of suicidal person being introduced *

Address of person being introduced

Contact us

Hours

Referral form

Visitor introductions – Please complete as much as possible or appropriate. (Please note that compulsory fields are marked by a red asterisk.)

Name of suicidal person being introduced *

Address of person being introduced

Contact us

Hours

Visitor introductions – Please complete as much as possible or appropriate.
(Please note that compulsory fields are marked by a red asterisk.)