Self Online Referral Form

Please complete this form to be considered as a referral for yourself. Review our privacy policy here.

About You


Only supply contact information that is safe for us to use. Please supply at least one contact method

More Information

Support Needs

Please note that for our Counselling Services, you will need to be at least 12 months free from using substances or alcohol and at least 6 months since any previous attempts on your life or incidents of self-harm. This will enable you to get the most from your therapy. However, our ISVA services are able to support anyone within those categories and someone at STARS will review your request to be referred and advise of what support we can offer.

In this next section we will ask you about the reasons why you are seeking support from STARS. Please note you do not have to report to the police to receive support from us.


Please tell us about your safety: