Make a Referral

Self Referral Form

If you are referring yourself to RoSA you can do so by securely providing your information below. One of RoSA’s specialist counsellors will contact you via your preferred choice.

Your name:*

Your contact phone number:*

Your email address:

Can we leave a voicemail? Please tick*
YesNo

Can we leave a text message? Please tick*
YesNo

What is your date of birth?*

What is your home address and postcode?*

How would you like us to contact you? Please select*
Mobile / TelephoneEmail (Non-sensitive information only)Post to your address

Do you have a preferred contact time?
MorningAfternoonAnytime

Are you over the Age of 18?*
I am over the age of 18I am under the age of 18

Your message:*

Refer Someone Form

If you are a GP; the police; a school; a statutory or voluntary organisation; a parent, family member or friend and would like to refer someone to RoSA, you can do so by securely providing your and your client’s information below. One of RoSA’s specialist counsellors will contact the referred client..

Your name:*

Organisation (if applicable):

Your contact phone number:*

Your email address:

The following information is about the person (Client) that you are referring to RoSA.

Has the person (Client) given their permission for the referral to RoSA and for RoSA to make direct contact with them?*
YesNo

Client’s Name:*

Client’s Date of Birth:*

Client’s Address:*

Client’s Contact Number:*

Does your Client have preferred contact time?
MorningAfternoonAnytime

Is your client over the Age of 18?*
I am over the age of 18I am under the age of 18

Your message:*