Wellies On The Ground Self-referral Form

First name

Last name

Birthday

Day

Month

Year

Phone

Email

Multi-line address

Country/Region

Address

City

Zip / Postal code

Preferred way for us to contact you:

Phone

Email

SMS

Is there a particular time that is best for us to contact you?

Time

HoursMinutes

Is there anything we should know before contacting you?

What would you like some support with?

Are you currently having thoughts about suicide or ending your life?

No

Sometimes

Yes

Prefer not to say

Are you currently hurting yourself or worried that you might hurt yourself?

No

Sometimes

Yes

Prefer not to say

Do you feel that you are in immediate danger right now?

No

Yes

Prefer not to say

Are you currently receiving support from another organisation or professional?

Yes

No

Not sure

If yes, who is currently supporting you?

Is there anyone you would like us to be aware of who is already involved in supporting you?

Consent

By submitting this form, I understand that:

The information I provide will be reviewed by a member of Cresco's Mental Health Team.
Cresco may contact me using the contact details I have provided.
Wellies on the Ground is a support service and is not an emergency or crisis response service.
Information I provide will be handled in accordance with Cresco's privacy and confidentiality procedures.
There are circumstances where information may need to be shared to protect me or someone else.

I agree to be contacted by Cresco regarding my referral.

SELF-REFER
FOR WELLIES ON THE GROUND SUPPORT

Consent

Need support right now?

SELF-REFER FOR WELLIES ON THE GROUND SUPPORT

Consent

SELF-REFER
FOR WELLIES ON THE GROUND SUPPORT