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Self Referral Form 

This form is for self referrals only - if you would like to make a referral on behalf of someone else please click here.  If you require any assistance filling our the form please don't hesitate to contact is on (0818) 303061 

Are you experiencing suicidal feelings 
If you answered yes, do you consider these thoughts 'Passive' - meaning you are thinking about but not actively planning on taking your own life? Or have you thought more deeply about suicide and considered how and when you would end your life?
Are you suffering from a diagnosed medical mental or physical condition, illness, or injury?
Have you been hospitalised in the last 12 months?
Are you currently abusing drugs and or alcohol
Are you self-harmng ?

Thanks for submitting!

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