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Refer Someone Form

If you are a GP; the police; a school; a statutory or voluntary organisation; a parent, family member or friend and would like to refer someone to RoSA, you can do so by securely providing your and your client’s information below. One of RoSA’s specialist counsellors will contact the referred client..

Your name:*

Organisation (if applicable):

Your contact phone number:*

Your email address:

The following information is about the person (Client) that you are referring to RoSA.

Has the person (Client) given their permission for the referral to RoSA and for RoSA to make direct contact with them?*
YesNo

Client’s Name:*

Client’s Date of Birth:*

Client’s Address:*

Client’s Contact Number:*

Does your Client have preferred contact time?
MorningAfternoonAnytime

Is your client over the Age of 18?*
I am over the age of 18I am under the age of 18

Your message:*