Self Referral

Please use this self-referral form to let us know of your situation and what help you need.

Use the message box at the end to tell us as much detail as possible.

We will be in touch after the inital referral form is received with any further questions we may have.

Name *
Email *
Safe to email? *
Telephone No *
Safe to call? *	Yes No
Preferred times to call *
Address *
What stage are you at in this relationship? *
Do you have any children who are also affected? *
How did you find us? *	Found on google Followed link from other site Friend told me Social media
What services are you interested in? *	Boundary Bridge (zero-contact service) Thrive! (Psychotherapy program) Both
Message *
	I understand that the information I provide will be kept confidential and only used to help determine how RISE Scotland can best support me. *
	I agree to be contacted by a team member to follow up on this referral. *

RISE Scotland is a Scottish registered charity: SC054497

0300 102 3268

info@risescotland.org.uk

RISE Scotland 2025

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