Welcome!

Harmless' Out of Hours Service is here to help people who are experiencing a crisis.

We want to ensure we can support you in the best way possible and by filling in this form, it helps us to make sure we have all the information to do that and helps us make sure we can keep you safe. It will take around 10 minutes to complete and then we can look at how we can support you tonight. If you'd prefer, you can give us a call and we can have a conversation with you, we still need to ask a few standardised questions before support is offered.
 
If you would like to do this over the phone with a member of staff please ring -  07925584716

 
We are unable to accept someone to the out of hours service without this being completed. But it really is so that we can do our best for you and so that we can agree what we can do to help.
 
This might be that we can support you remotely, by phone or chat, or that we can see you face to face.
 
Please note: Harmless hosts its out of hours service on Thursdays in East Leake. 
 
What you can expect of us and what we will expect of you: Our Charter
 
  • Our out of hours services offers a relaxed environment for those in mental health crisis to work alongside staff to develop solutions and positive outcomes to their current distress. 
  • This space aims to provide a sense of hope and safety ensuring that you receive appropriate advice and guidance to best meet your needs.
  • Whilst in the service we ask that you treat others and the environment with respect.
  • We will work alongside you to develop solutions and play an active part in your crisis management planning.
      • Whilst in our service we ask that visitors refrain from self-harm. We are a place to come to move forwards and it is important that you use the time with us to get the best possible support. Any self-harm on-site would require a review and it may be considered that the service can no longer support you at this time.
      • Anyone using or threatening violent/intimidating behaviour will be asked to leave.
      • The Police may be informed of any criminal activity and will carry out their own investigation.
      • To ensure a safe space for everyone, no animals/pets are allowed in the cafes with the exception of assistance animals.
      • Carers are welcome to attend with you.
       

      Question Title

      * 1. Today's date

      Date
      Time

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      * 2. Is this an agency referral

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      * 3. Name and contact details of referrer
      (skip this question if not applicable)

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      * 4. Personal details of the person needing help

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      * 5. Is the person at their place of residence at present?

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      * 6. Date of Birth of person needing help

      Date

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      * 7. Gender

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      * 8. Ethnicity

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      * 9. What is your sexual orientation?

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      * 10. What is the employment status of the person needing help?

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      * 11. Next of kin details

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      * 12. Do we have permission to make contact with them? **We will only breach confidentiality without your consent if there is imminent risk to you or someone else. For more details, please ask.

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      * 13. Has the person needing help been using alcohol in the last three hours?

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      * 14. Has the person needing help been using substances in the last three hours?

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      * 15. Does the person needing help have any history of violence towards others?

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      * 16. Do you have a mental health diagnosis/difficulty?

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      * 17. Do you have a physical health diagnosis/difficulty?

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      * 18. Please answer the following questions on a scale of 0 to 10 where 0 is not at all and 10 is a lot. If the question is not relevant to you then the answer will be '0'.

        0 1 2 3 4 5 6 7 8 9 10
      1. I am thinking about hurting myself?
      2. I am planning on hurting myself?
      3. I am thinking about ending my life
      4. I am making a plan to end my life
      5. I am able to tolerate my distress
      6. I am able to tolerate my thoughts
      7. I feel positive about my relationships with your friends and family
      8. I feel positive about my daily activities (e.g. school or work)
      9. I feel positive about the future
      10. I am in a mental health crisis
      11. I am in a suicide crisis
      12. I am likely to harm myself (without intervention)
      13. I am likely to harm someone else (without intervention)
      14. I am in distress
      15. I am likely to consume alcohol
      16. I am likely to consume substances
      17. I am likely to behave recklessly
      18. I feel safe
      19. I am unable to cope
      20. I feel hopeless

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      * 19. If you are unable to get help from Harmless' Out of Hours Service, what do you think will happen?

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      * 20. If you are unable to get help from Harmless' Out of Hours Service where else will you look for support, or what services will you use?

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      * 21. Where is the person needing help right now?

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      * 22. We offer remote support with some face to face availability, what is your preference?

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      * 23. Do you have any dependents at home?

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