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Make a Referral

If you’re in need of support, or you know someone who is, you can use this form to make a referral to RSASS. 


If you’re referring on behalf of someone else, please ask their permission first. We cannot take referrals where consent has not been given. 

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Using the form

This referral form is confidential. Any details you share with us will only be used by RSASS to ensure you get the care and support you need. We will only share information if we feel there is a safeguarding risk to you or the person you are contacting us about. If you’d like to know more about how your details are handled, you can read through our Privacy Policy


If any of the questions below make you feel uncomfortable, you can leave the section blank. Sections that are required will be marked with an asterisk. 

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What happens next

Once we have your form, we will be in touch via phone or email to set up an initial  appointment. This can be face-to-face (either in-person or via Teams) or by telephone. 


During this appointment, you’ll have the opportunity to tell us about your experience.  We’ll guide you through our services and how we can help so that you can tell us what support you’d like to receive.


If you decide you’d like support from us, we can then sign you up to these services. We can also provide information on potentially beneficial services outside of RSASS and help you refer yourself to these. 

Talk to us

If you need any advice on filling out this form, or if you would like more information about RSASS and what we do, we will be more than happy to help. Call us on 01494 358486 or email us at Our current response time is within 24 hours. 

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Referral Form

Are you referring on behalf of a third party?
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