Relax, Reset, Recharge: A 3-R Pathway to Wellbeing from Here For Each Other

Here For Each Other has designed a four-week online wellbeing program to support staff who are signed off sick from work (for at least six weeks) with some form of mild stress, anxiety, low mood, self-neglect or other condition. 

Please complete the form to refer yourself or a member of staff to the program.

Date of referral *

January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031

Name *

Date of birth *

January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031

NHS number *

RiO number *

Referred by *

Reason for referral (Referral criteria: MUST be off work 6 weeks or more with one or more of the following: mild stress, mild anxiety, low mood, or self-neglect where you have assessed the risk of self-harm, suicide, or other complex mental health issues) *

Why has the client been signed off sick? *

Do you have consent from client for this referral and is the individual ready and willing to participate in the course for the full 4 weeks? *

Has the client tried to improve their general wellbeing whilst being off work? *

Any other information we should be aware of? *

Professionals