Self Referral Form

Thanks for choosing to register with the Staff Wellbeing Hub. This form takes one to two minutes to complete. Your information will be kept confidential within the Staff Wellbeing Hub secure recording system. You also have the option to contact the hub anonymously if you prefer.
This form is received by the hub between 9am - 5pm on Monday to Friday, except bank holidays. If you need immediate support please contact your GP or local Crisis Service.
If you would like to remain anonymous, please complete the form in full and use an anonymised name and address so that we can easily identify you in future contacts. Please provide a real phone number or email address so we can contact you.
Please only complete the remaining following questions if you are completing the form on behalf of someone else, and only if you they are happy for you to do so.