(Please note that compulsory fields are marked by a red asterix.)
Name of person making referral *
Email address of person making referral *
Please take care when entering an email address into the box above, as this can affect the form arriving with us successfully. If you are in any doubt that your referral has been received, please do call to check that the form has been received on 020 3906 7676.
Name of organisation making the introduction *
Postcode of organisation making referral *
Phone number of person/organisation making introduction *
Name of person being introduced *
Reason for referral *
Telephone number of person being introduced *
On a scale of 0 to 5, 5 being the highest, how distressed would you estimate this person to be? *
Please note that Coronavirus (COVID-19) Key Workers do not need to feel that life is no longer worth living, to access support through The Listening Place.
On a scale of 0 to 5, 5 being the highest, how suicidal would you estimate this person feels? *
The Listening Place volunteers are trained to offer ongoing active listening support for people in times of suicidal crisis; however, during the current health crisis, our volunteers will also be able to offer free, totally confidential, ongoing support to key workers via telephone appointments.
Gender of person being introduced
Date of birth of person being introduced (dd/mm/yyyy)
Address of person being introduced
Email address of person being introduced
General presenting reason for appointment at The Listening Place *
If suicidal, what is the nature of these thoughts? *
Visitor expectations of The Listening Place *
I consent to having this website store my submitted information so The Listening Place can respond to my submission. *
0 + 5 = ?Please prove that you are human by solving the equation *
Hestia: A charity, working together with adults and children to change their lives at the times when they most need support.
Maytree - A sanctuary for the suidical
UK SAYS NO MORE - A campaign to raise awareness and bring an end to domestic violence and sexual assault
Nightline - We are students there for students
3 Meade Mews
London SW1P 4EG