Refer yourself

If you would like support from Gateway 4 Women, you can complete the form below. Choose the centre you would like to hear from and your referral will be directed to the appropriate team.

Self-referral

You don't need to know exactly what support you need

Complete the short form to tell us who you are, which centre you would prefer and how you think we may be able to support you. You don't need to know exactly what support you need before getting in touch.

Is it safe for us to contact you?

If someone else may have access to your phone, email or messages, please tell us how and when it is safest to contact you.

If you are in immediate danger, call 999.

1. About you Full name Date of birth Contact number

2. Is it safe to contact you?

Please let us know whether it is safe for Gateway 4 Women to contact you using the number above.

YesIt is safe for Gateway 4 Women to contact me. NoPlease do not contact me using this number without discussing a safe alternative.

If there is anything we need to know about contacting you safely

3. Preferred centre

Choose the Gateway 4 Women centre you would prefer to access. This will determine which team receives your referral when the secure form is connected.

Carlisle17a West Tower Street, Carlisle, CA3 8QT WorkingtonFirst Floor, Cumbria House, New Oxford Street, Workington, CA14 2NA

4. How would you like us to support you?

You don't need to know exactly what support you need. Tell us in your own words what is happening for you and what you think might help.

What would you like support with?

5. How did you hear about us? How did you hear about Gateway 4 Women? If you selected other, you can tell us here

Before completing this form, please read our privacy notice to understand how personal information will be handled.

Important before this form goes live

This is currently a website draft and does not transmit your information. Before launch, it should be connected to a secure referral system so personal information is handled appropriately and the referral is routed to the selected centre.

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