SELF REFERRAL

You can use the form below for a referral, or self referral, to Seed Sessions.

If you’re in crisis and require immediate help, please consider dialling 999, or you can find support from the links listed below.

Bristol Samaritans – www.samaritans.org/branches/bristol/
The Sanctuary – Bristol – www.second-step.co.uk/our-services/community-and-wellbeing/the-sanctuary-bristol/
OTR Bristol – www.otrbristol.org.uk

Seed Sessions Self Referral Form

Is this referral for yourself, or are you referring someone else?(Required)

I'm referring myself

I'm referring someone else

Referring Someone Else

If you're referring someone else to us, please complete your details below, then continue to fill out the rest of the form with as many details as you can.

Referrer Name(Required)

Referrer Email(Required)

Referrer Contact Number(Required)

Relationship to Person You're Referring(Required)

Is the person aware you're making the referral?(Required)

Yes

Please include any other relevant details about you or your relationship with the person you're referring that you think we'd need to know.(Required)

Referral Details

Please fill this out with the participants details, to the best of your knowledge

Please fill out this form with as much detail as possible, but do reach out via email or our contact form if you're having difficulties.

Your Name(Required)

Your Email(Required)

Your Address(Required)

Street Address Address Line 2 City ZIP / Postal Code

Your Date of Birth

DD slash MM slash YYYY

Your Phone Number

Next of Kin (name and phone number)

GP Name and Surgery

Ethnic Background(Required)

Other Ethnic Background(Required)

Music Questions

What genres of music do you like and whose music do you find inspiring?(Required)

What do you do musically?(Required)

Success is different for everyone. Can you identify an aim you would like to achieve from the music sessions?(Required)

Personal Questions

Have you had counselling (or similar) before? If yes, please provide brief details (e.g. what type of therapy and what worked / didn't work for you)

Please tick any that you have been affected by (directly or indirectly):

Substance / Alcohol Abuse

Broken Family Relationships

Abuse / Neglect

Gender issues

Mental Health problems (depression / anxiety / PTSD / suicidal thoughts etc)

Disability

Serious physical illness

Life in care / Homelessness

Eating Disorders / Self Harm

Grief

Experience of Criminal Justice System

Other:

Affected By Other

Can you identify anything in particular you would like to work on throughout the counselling sessions? (just general - no need to share personal info)(Required)

Please write a paragraph or so on why you are requesting support from Seed Sessions...(Required)

How did you hear about Seed Sessions?(Required)

Hearabout Other