Self-Referral Form

Use this service to submit your interest in receiving counselling and support from Off The Record South.

If you are an Agency or Professional, please click here

This service is available Young People aged between 11-25 residing in the Havant Borough Area.

Submission takes around 15 minutes.

If you need urgent help or support in a crisis

Off The Record South East Hampshire is not crisis/urgent support. If you need more immediate support please consider the following:

Please note we cannot work with people under an Adoption or Special Guardianship Order. Please contact Barnardo's for further information and support.

Before you start

You cannot register for this service if you live outside of the UK.

Eligibility Check

This section is to ensure that you reside within Off The Record South East Hampshire’s catchment area and are within the age range we provide services for. This section also confirms your consent to several OTR policies before continuing with the referral process. Please contact OTR with any questions or concerns.

Please note that GP surgeries are often listed under their merged name, e.g. Vine Medical Group, rather than the individual sites. My GP is not in the list above

Client Consent:

Service Options:

Please tick the service option(s) you wish to receive:

Self Referral Form

Information about you

Why do I need to provide this information?
Please indicate your gender identity.

Contact information

Please provide a phone number and email address that you consent to OTR South using for weekly support calls, to make and confirm appointments with you, and general service information.

Emergency contact information

Please provide a phone number for use in an emergency.

How we contact you:

Please indicate your preferred method(s) of contact for general information (please note that support calls and allocating a counsellor to you will always be done by telephone)

Work/Education Status

Are you a member of or have you ever served in the Regular/Reserve Armed Forces?

Are any immediate members of your family a member of or have ever been a member of the Regular/Reserve Armed Forces?

What are the main reasons you would like to have counselling support?

Issues you would like support with:

Please select a minimum of one. The more information you provide the better we can support you.

Factors about your life you would like support with:

Please select a minimum of one. The more information you provide the better we can support you.

Availability Information:

While on the counselling waiting list you will receive a weekly support call from one of our Support Workers. It is important for us to keep in touch with young people on the waiting list to make sure they are still interested in counselling and wish to stay on our waiting list. It is also important that contact details and counselling preferences can be regularly updated. Please note – if weekly support calls are not answered for 5 weeks, you will be removed from the waiting list.

Please indicate your availability for counselling sessions and how you would wish to receive counselling. Please note, the greater your availability and flexibility in channel of counselling, the easier and potentially quicker it will be to allocate a counsellor to you.

Please provide here any specific day and time availability that you can do counselling on in detail:

Contact Us

  • Call us on:
    023 9247 4724
  • Groupwork only:
    023 9278 5111 or
    07923 400520
  • Young Carers only:
    07709 552130
  • Email us at:

  • We are open:
    Monday to Friday
  • We aim to respond to emails within 2 working days. Our phone lines are open every day at different times, if you don't get through first time please leave a voicemail with your phone number and we will respond within 2 working days.