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Self Referral Form
This form is for self referrals only - if you would like to make a
on behalf of someone else please click
If you require any assistance filling our the form please don't hesitate to contact is on (0818) 303061
Select an Address
Reason For Refferal
Are you experiencing suicidal feelings
Do you consider these thoughts 'Passive' - meaning you are thinking about but not actively planning on taking your own life? Or have you thought more deeply about suicide and considered how and when you would end your life?
Are you suffering from a diagnosed medical mental or physical condition, illness, or injury?
Have you been hospitalised in the last 12 months?
Are you currently abusing drugs and or alcohol
Are you self-harmng ?
Emergency Contact Name
Emergency Contact Number
I hereby confirm that I have read and agree to the terms and conditions. I further confirm that all information provided is accurate and correct.
Thanks for submitting!
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