Branching Out: Self Referral Form

Branching Out: Self Referral

For completion by the person referring themselves for support.

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Contact Information

Please provide information on how we can contact you.

Please select at least one.

Please provide your telephone number

Disadvantages

You must be experiencing two or more of the following to qualify for the service.

Please tick all that apply.

Risk

If you feel that you are currently a risk to yourself or others, or that you are at risk from someone else, please provide details.

Medical Conditions

E.g. severe allergies, epilepsy, heart conditions, diabetes.

Declaration

By submitting this form, you confirm that you feel able to maintain your safety while waiting for your referral to be processed, and that you feel able to contact crisis services if you need to, such as:  

How We Use and Store Data

Oakleaf is the data controller of the information you have provided. Due to the nature of our work with you, we will, from time to time, collect personal data which will include special categories of personal information. Beyond your name, date of birth and contact details, this data may also include information about your health and other personal characteristics you may have shared with us. This will allow us to take any reasonable steps to accommodate specific needs or requirements you have when providing our services to you and we require your specific consent to process this information. Full details can be found in our Fair Processing Notice.  

Your referral is almost complete...

To submit your form, please press the 'send' button below. Your referral will be sent to our Outreach Worker who will contact you within 7 working days.