Self Referral Form Devon | Pete's Dragons

Do you have any accessibility requirements?

Emergency contact detailsFull name:

Contact number:

What is your relationship to this person? (I.e. best friend)

Medical information:GP name (if you don't know their name, please put N/A):

Surgery name:

Surgery address:

Relevant medical conditions and medication (if you have none, please put N/A):

Could you share with us the full name of the person who died by suicide:

Could you please also share the approximate date of their death?

Did they die in Devon? if not, please list where.

What was your relationship to the person who died?

Is there anything else that you think it would be useful for us to know at this stage?

How did you hear about Pete's Dragons? (please select from the drop-down menu)

If other, please specify:

Have you ever contacted or received support from Pete's Dragons before?

YesNo

If yes, please explain more:

Are you currently receiving any support from any organisation?

Nearly there, the final step is to read through the below copy of our service agreement. You will need to tick the box to confirm that you understand and agree to our terms of service. A copy of this agreement will be sent to you upon your referral and you can remove your consent at any time.
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If you've got any questions to do with the service agreement, you will have a chance to speak to the team once this form has been received:

Pete's Dragons Service Agreement
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At the start of our support, everyone will receive what we call practical and emotional support and listening. This will give you a chance to talk to openly, the space to build a relationship with us and we can get to know you and your needs. We may well move you into a different type of therapy later, but we would always do that with your full consent.
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We are unable to offer advice regarding medication. You may find that once you’ve been using the service for a while you begin to feel much better and question whether you still need any medications. Please always consult your doctor before changing any dosage.
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Everything you say to a member of the Pete’s Dragons team is confidential within our organisation. We may at times use your information to help in the reduction of suicides or in evidencing the impact and importance of our service, this is always anonymised or presented as statistics or numerical data.
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The only time we breach your confidentiality is if we think you or anyone else is at risk of harm.
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Pete’s Dragons is fully GDPR compliant, and all of your data is stored securely.

Pete's Dragons work very hard to operate without waiting lists which means your support will begin almost immediately, we are however a very small team covering a very large county and therefore can not guarantee appointments at specific times of the day. We will however, always try our best to accommodate your needs.
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Our staff are highly trained and experienced and many of them personally bereaved or impacted by suicide. We like to make it clear that they are not permitted to talk about the details of that death, however they can and are likely to share their recovery with you.
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We are more than happy for you to cancel appointments but would appreciate as much notice as possible so that we can give the slot to someone else. If you don’t cancel an appointment, we will get worried about you and may contact your emergency contact.
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Please be aware that appointments arranged are solely for you, we are unable to provide support for people who have not referred into our service and made their own appointment. If you bring someone along with you, they will not be able to enter the Therapy Room and some of our offices have limited waiting areas.

Pete's Dragons work very hard to operate without waiting lists which means your support will begin almost immediately, we are however a very small team covering a very large county and therefore can not guarantee appointments at specific times of the day. We will however, always try our best to accommodate your needs.
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Pete’s Dragons have a zero-tolerance policy on drugs/alcohol and rudeness and aggression.
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Pete’s Dragons operates Monday to Friday, 9am to 5pm, calls and emails are not monitored outside of these times.

When it becomes time to leave our service, we will ask you to complete a short feedback survey which helps us to constantly learn and improve.

By ticking this box I acknowledge thatI have read, understand and agree to the outlined terms of service

Get support in Devon

You may want to gather the following information together before you begin:

Complete the form

Thank you

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