Self-Harm support group - Referral form

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Thank you for your interest in our self-harm support group. A support group intending to support those caring for someone who Self-harms .

This is NOT direct support for individuals who Self-harm .

Please add your details below and we will send you a joining link to the monthly support group.

Email *

Your Name *

Please confirm you are aged over 18

Yes

No (Please email us for advice if you are wanting to attend and under 18yrs old )

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Referral date *

YYYY

Reconfirm your email address *

Your Home Address *

Your Home postcode *

Your Phone number *

Your relationship to the person you are supporting? *

Age of person you are supporting? *

Any additional information you would like to provide ?

Send me a copy of my responses.

Submit

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