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Sutton Crisis Café: Before you visit
0800 012 9082
crisiscafe@smhf.org.uk
suttoncrisiscafe.org.uk
6:30pm to 11pm (last admission 10:30pm), 7 days a week, 365 days a year
63 Downs Road, Belmont, Sutton, Surrey SM2 5N
It is very helpful to know a bit about you and how you think we can help before you visit Sutton Crisis Café.
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About you
Full name
*
First
Last
How would you like us to address you?
Gender
*
Male
Female
Non-Binary
Prefer not to say
What pronouns do you use?
He/Him
She/Her
They/Them
Other
Pronouns
Ethnic group?
*
White
Mixed/multiple ethnic groups
Asian/Asian British
Black African/Caribbean/Black British
Other
Prefer not to say
Date of Birth
*
DD
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YYYY
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Please note: We only accept referrals for those aged 18 or above.
Address
*
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
How may we contact you?
*
Telephone
Email
Text
Please select all that we can use
Preferred method of communication
Telephone
Email
Text
Telephone number
*
Can we leave an answerphone message?
*
Yes
No
Email address
*
Please tell us how we can help you:
*
Do you feel you are a risk to yourself?
No
Yes - low risk
Yes - medium risk
Risk to self
Do you feel you are a risk to others?
No
Yes - low risk
Yes - medium risk
Risk to others
Do you feel at risk from others?
No
Yes - low risk
Yes - medium risk
At risk from others
Next
Please let us know if there is anything else we should know about:
Special requirements
Triggers
Health issues
Disabilities
Please select all that apply
Please let us know if there is anything else we should know about:
Any further comments?
Other helpful information
How did you hear about us?
*
Please select
Belmont Connect
E-news
Leaflet / poster
Online
Recommended by mental health services
Social media
Word of mouth
Other
Do you live within the London Borough of Sutton?
*
Yes
No
I'm not sure
Which local authority do you live in?
*
Have you visited Sutton Crisis Café in the past?
*
Yes
No
Are you currently attending any other mental health services?
*
Yes
No
Have you in the past?
Yes
No
Do you require an interpreter?
*
Yes
No
In which language?
*
Emergency contact information
Someone we can contact on your behalf in the event of an emergency.
Do you have an emergency contact?
*
Yes
No
Emergency contact name
*
Emergency contact number
*
Relationship to you
GDPR Agreement
*
I consent to having SMHF/this website store my submitted information so that Sutton Crisis Cafe can respond to my inquiry.
By submitting this form you consent to your demographic information (age, gender, ethnic group & local authority) being shared in an anonymised form for monitoring purposes.
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