Jak’s World

Referral Form

Jak’s World

Referral Form

JaksWorld offers a range of community-based well-being services to support individuals who may feel isolated, overwhelmed, or in need of a safe space to connect.

IMPORTANT: If you or someone you know is in immediate danger please contact the emergency services on 999. If you need to speak to someone urgently Samaritans are available nationally 24 hours a day on 116 123. hubofhope.co.uk can also provide a comprehensive list of services available in your area.

We may be required to share some personal data under the terms of our contract for funding purposes. We provide this as a group statistic rather than individual information. We will always ask your permission to share your experience as a case study and you will have the opportunity to decide who and how we share this.

Details of the data we hold and how long we keep it for can be found in our Privacy Policy at the bottom of the website. By submitting this form, you are agreeing to the information presented above.

About you:

Full name *

Date of Birth *

Email *

Address

City

Postcode *

What is your local A&E? (for example, Salford Royal, Trafford General etc.) *

Support Information:

REASON FOR CONTACT (need advice/support for) (select one or more) *

Yourself

A friend or a family member

Other (Please provide more details)

Extra info:

Are you in SUICIDAL crisis? *

Yes

How can we help you? Please give a reason for contact. *

Emergency Contact Name *

Emergency Contact Number *

CIRCUMSTANCES (If applicable, please tick all the circumstances which apply to you) *

Low Income/Financial Crisis/Debt

Drug/Alcohol misuse

Previous Suicide Attempt

Bereavement (by suicide or otherwise)

Relationships

Long term illness/Other physical health issues

Mental health crisis/diagnosis

Trauma

Recurring thoughts or self-harm/suicide

Extra info:

If you have a mental health diagnosis, please let us know here:

Are you currently being seen by a Mental Health Service?

Yes

If yes, please tell us which service:

Referral Information:

If you are referring someone, please provide your details below. All details are optional.

Referrer name

Referrer Agency/Organisation

Referrer contact number

Understanding your immediate support requirements:

Consent

Your privacy is important to us, and we want to communicate with you in a way which has your consent and is in line with UK law on data protection. If you would like to opt out at any point, please email TalkToUs@jaksworld.org.

I give my consent/the person I am referring has given their consent for Jak's World Charity to make contact via: *

Post

Telephone

Text

Marketing and promotional purposes

Charity updates

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