Crisis Cafe Registration Form

Your name

Date Of Birth (DOB)

Address

Postcode

Phone Number(s)

Email Address

Registered GP Surgery

Emergency Contact Name & Number

What brings you to the Crisis Cafe today? How can we help you? (optional)

Current health or support needs (e.g. physical or psychiatric problems/diagnosis and other professionals involved) (optional)

In order to offer you the most appropriate support, please tick if any of these apply to you: (optional)
Victim of harassmentAnti-social behaviourTraumaVictim of domestic violence/sexual assaultUnder ProbationGambling issuesSexual OffencesAlcohol/drug misuseIsolation/lonelinessVeteran / Armed forcesPain/Physical healthSelf-harmSuicide attemptsSuicidal thoughtsOther (please tell us below)

Please tell us more, and tell us about any mental health triggers (if known) (optional)

Please tick if you would like support with any of the following issues:
Money/BenefitsVolunteeringPhysical healthCommunity groups & activitiesFamily/Caring RolesUtility BillsEmploymentMental healthAddictions / substance misuseHousingCounselling

Consent and service questions:
If this service wasn't open, where would you have gone?

Any mental health team involvement? If so, which one?

Permission to store your information confidentially?

Permission to share your details with other professionals in regard to your safety or further support?

Onward referrals to other support services? If so, which ones?

Has a safety plan been put in place?

Would you like a follow-up call from one of our team?

Terms of Service: Adults must be 18+. We aim to create a therapeutic environment. If we feel that we cannot meet your needs we may signpost you to another source of support.
By ticking the box below, you are agreeing to the terms of service:
I agree to the terms of service and can confirm that all the details given in this form are, to the best of my knowledge, true and accurate