WASS Self Referral

Request WASS support for yourself

To request support services provided by the Maninplace WASS project, please complete the form below, providing as much detail as you are able. Our outreach support worker will review your referral and make contact to arrange an appointment.

If you require assistance with completing forms and are unable to submit this referral by yourself, please call us to arrange a telephone referral appointment on 01952 248248.

Self referral form

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Self Referral

To ensure we can respond to your referral for support and assistance, please provide as much infomration as you can. Once we have recived your completed form, one of our outreach workers will make contact with you at the earliest opportunity to arrange a follow up appointment.

Personal Details

Name *

First

Last

Date of Birth *

Email

Email

Confirm Email

Gender Identity *

Phone *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Who is your current housing provider or landlord?

What is the best way for us to contact you? *

• Call
• Text
• Email
• Letter

Next

About your needs & risks

This information is required to allow our support workers to prepare for your assessment fully. Please give as much detail as you can, especially if you believe you are at urgent risk of harm. All infromation shared in this form will be held confidentially.

Have you been involved in any incidents of violence or aggression? *

• Yes
• No

Violence or aggression: If you have answered "yes", please tell us about this, when it happened, and if you have been refused help from other services because of this. *

Have you ever been investigated, cautioned or charged with an Arson offence? *

• Yes
• No

Arson incident details: Please provide details about the incident, when it occurred, and if you are subject to any restrictions imposed by a court. *

Do you have any Criminal convictions or have you ever/are you currently being investigated by the police? *

• Yes
• No

Criminal convictions: If you have answered "yes", please tell us about this. *

Have you/are you experiencing Domestic Abuse?

• Yes
• No

Are you currently at risk from others? Do you feel safe? (friend/family/visitors) *

• Yes
• No

Risk from others: If you have answered "yes" and you feel able to, please tell about the rhese risks.

Have you ever self harmed?

• Yes
• No

Self Harm: If you have answered "yes", please provide some brief details about this.

Have you ever had suicidal thoughts?

• Yes
• No

Have you ever acted on these thoughts?

• Yes
• No

Are you experiencing poor Mental Health? If yes, please provide details

• Yes
• No

Poor mental health: If you answered "yes", please tell us about your current mental health issues.

Do you use substances/alcohol?

• Yes
• No

Substance/alcohol use: If you answered "yes", please tell us more details about this.

If you would like to tell us anything else about the support you need, please tell us about it here.

Next

Referrer's Signature

GDPR Agreement *

• I consent to having this website store my submitted information so they can respond to my WASS support referral.

Signature *

Clear Signature

Date of Signature *

Submit