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Professional prevention referral

Suicide prevention referral form

The assessment will be based upon the information you provide.
Please provide as much detail as possible to ensure we can support those in need.

Please complete all details entering “N/A” in the box if not applicable.

Has consent been obtained for referral?

Yes No

Details of referrer

Details of referred person

Yes No

Next of kin details

GP details – please provide complete information

Is the supported person currently been seen by any other service - i.e. crisis team, secondary mental health care, support worker, nurse practitioner, psychiatrist, third sector, family carer… (not definitive list)

Yes No

Details of suicidal crisis (please be a detailed as possible)

Are their current difficulties related to any of the following factors?

Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No

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