Staff Welfare Referral

After completing this form, we offer an initial telephone assessment which usually lasts up to 30 minutes in which we explain what we can offer, ask a few questions and discuss what you want from our Service. Here is a link to our website with further information on the service we offer.

Your Details

First Name

Last Name

Contact Telephone

This will be used by the Staff Welfare team to contact you for assessments and appointments. You can use a personal telephone number, if you prefer.

This will be used by the Staff Welfare team to contact you for assessments and appointments. You can use a personal email, if you prefer.

Preferred method of contact for initial appointment

Department you work for

Department Area

(e.g. Name of School, Hospital Ward, etc)

Referred by

Please specify

Is there anything you would like to make us aware of before your initial assessment?

Declaration

I confirm that the details I have provided are correct