Self-referral form

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

If you have any questions that are not addressed by our “FAQ” in the “I need help” section, please always feel free to get in contact. Our telephone number is 020 3906 7676 and we are available to answer question from 9am to 5.30pm; or alternatively you can reach us via email

Name*

First*

Last

Main phone number*

Additional telephone phone number

On a scale of 1 to 10, 10 being the highest, how suicidal do you feel?*

On a scale of 1 to 10, 10 being the highest, how likely to kill yourself would you say you are?*

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

Date of birth:

Address

Address line 1:

Address line 2:

Address line 3:

Address line 4:

Postcode (or if you do not have a fixed address, please write "no postcode") *

Did any organisation refer you to get in contact with us? Please give details.

Your main reason for wanting to attend The Listening Place

Nature of suicidal thoughts *

What are your expectations of The Listening Place*

Confirmation*

I confirm that this information is correct, and that I wish to refer myself for support with The Listening Place. For more information on our Privacy Policy please Click here. I understand that The Listening Place’s volunteers offer listening by appointment only, and that they will get in contact with me as soon as possible using the contact details I have provided. However, if I am in need of immediate or urgent help, I know that I will need to please contact 999, emergency services, or an NHS medical or mental health provider.

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Self-referral form

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

Name*

Address

Contact us

Hours

Self-referral form

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

Name*

Address

Contact us

Hours

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