Active Monitoring

Active Monitoring
Referral Form

If you feel like you need help to manage your emotions,
sign up to our free guided self-help service here.
We accept registrations from young people (11+)
and adults based in any of the areas found here

We are NOT a crisis service and are not the best service
for you if you are very distressed, despairing, or suicidal.
If you are in a crisis, please call Samaritans at 116123

Connection is a 24/7 phone helpline for people of all ages
in Dorset who are experiencing mental health issues and need support.
Call 111 and select ‘mental health’ or dial 0800 652 0190
to access support as part of the Dorset Crisis Response Service.

Shout 85258 is the UK’s FREE, confidential, 24/7 text support service.
Text the word ‘SHOUT’ to 85258 and you will start a conversation with a trained Shout Volunteer, who can help if you’re struggling to cope and need mental health support.

1About You

2Emergency Contact and GP Information

3Parent/carer/guardian details

4Details of referrer

5Data Protection and Confidentiality

Who is this referral for? *

Myself
On behalf of someone else

Please let us know about the main mental health concern that you have/ the reason why you have referred *

Name *

First

Last

Date of birth *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Phone *

Email *

Layout

Can we text you? *

Can we leave you a voicemail? *

Active Monitoring

Active Monitoring Referral Form

Active Monitoring
Referral Form