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.


Client Agreement:

Service Options:

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

Young People Services

OTR offers services to young people who reside in the Havant Borough and East Hampshire area (young carers is Havant Borough only) Please see the services below for the age range they are applicable to.

Parent/Carers Services

OTR offers services to Parents and Carers of 11-25 year olds who reside in the Havant Borough and East Hampshire area to help support yourself, your young person and your family. Your young person does not need to be actively waiting or participating in OTR’s services for a parent/carer with us.


Self Referral Form


Information about you

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

If you cannot find your GP, please select the ‘GP Not Listed’ option. OTR will contact you shortly after registering to establish your GP surgery to update your record. My GP is not listed

Contact information

Please provide a phone number and email address that OTR South can use for weekly support calls, to make and confirm appointments with you, and general service information. Without this information, OTR will be unable to provide our services to you. Wherever possible, please can this be the client’s personal and direct contact 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?


Do you know anybody at OTR?

If you know anybody at OTR, whether past or present, whether definite or a maybe, whether a client, support worker, counsellor or other staff, please provide their names below:

Issues you would like support with:

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

Please tell us about other factors and experiences you have had been affected by in your life:

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
  • Email us at:
    enquiries@otr-south.org.uk

  • 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.