Thank you for considering self-referral to get help for yourself. We understand this may be a difficult time. To help us to help you there are some questions we need to ask.

To complete this online referral you will need the consent of your parent / carer.

This request for support is aimed at young people aged 12-18 years for young people that are resident in South Staffordshire (excluding both the City of Stoke-on-Trent and North Staffordshire Moorlands).

We protect personal information under common law rules of patient confidentiality, and will share information with those members of our partnership who are providing care.

For more information, please read our Privacy Policy at Information Governance.

About You

Your Date of Birth Required
Your gender Required

About your Parents / Carers

We need to collect some contact details about one of your parents / carers.

Is your parent / carer aware you are self referring? Required

Contacting You

Can we telephone you? Required
Can we text you? Required
Can we email you? Required

Your worries and concerns

Are you getting any help or support for these concerns / worries at all? Required
Have you received any help or support for these worries / concerns before? Required
Are you on any medication? Required

Protecting You

Have any thoughts around harming yourself today? Required

If you require medical advice, call 111.

If you require urgent 24/7 mental health support call 0808 196 3002.

Do you think you may harm yourself in the future? Required
Have your hurt yourself in the past? Required
Do you think you might be hurt by someone else? Required

If yes, please contact First Response to inform them of this: 0800 131 3126

Any other information?

What happens next?

Thank you for taking time to fill out this form, this is a huge step forward to getting yourself or a loved one the support they need.

We aim to review your information within a week.

Your health, wellbeing and safety is of top priority to us. You will be contacted as soon as posible.

Completing this will lead to your request being considered by emotional support services across South Staffordshire.

Please note: if you wish to send us additional supporting information (such as reports from other health or social care professionals), send them as email attachments to, and be sure include your name, date of birth, and address within the email which will allow us match this correspondence to your referral.

Do you consent to us contacting you for feedback about your experience of self referral? Required


If you need help in the meantime contact your doctor, visit a NHS walk-in center or call NHS 111. If it is an emergency, dial 999 or visit A&E.

More information and places for support:

It's important to talk to friends, family members, and others that you trust about your feelings.