Mental health referral form

Please fill in this form to ask for support from one of our mental health first aiders.

Please note: the information in the form will be emailed to our wellbeing champion, Fiona Dowling. She may forward it to one of our qualified mental health first aiders.

We will need to keep the information so we can keep track of requests. But we promise we will not share it outside VGC.

Wellbeing support form

Fill in this form if you would like a VGC mental health first aider to contact you. Everything will be strictly confidential.

Name
First Last
Phone
Email
Let us know how you'd prefer to be contacted, and what time of day would suit you best.*
Is anything in particular worrying you?
(You don't have to give any information here if you don't want to.)
- Work
- Finance
- Relationship
- Health
If you want to give any more information, please use this box