Mental Wellbeing Referral Form

Personal Information

Name

Street Address

Address Line 2

City

County

Postcode

Home Phone

Mobile Phone

Email Address

Date of Birth

Do you have any children?YesNo

Are you currently pregnant?YesNo

Employment StatusEmployedSelf-EmployedUnemployed

Referral Information

What kind of Referral are you making?Self ReferralReferred

Referrer's NamePlease provide the details of the person MAKING the Referral

Street Address

Address Line 2

City

County

Postcode

Contact Number

Email Address

Emergency Contact

Please provide the name of a person to contact in case of an emergency

Name

Street Address

Address Line 2

City

County

Postcode

Relationship to Referee

Telephone Number

General Practitioner (GP)

Please provide details of the Referee's GP

Name

Street Address

Address Line 2

City

County

Postcode

Telephone Number

Relevant Information

Please let us know about the difficulties being experienced, or any details of the Referee's mental health

Other Mental Health Difficulties

Would you be interested in Holistic Therapies?YesNoIs the Referee interested in Holistic Therapies offered by us to improve wellbeing (ie Reflexology, Massage, Mindfulness, Aromatherapy)

Which services would you be interest in?ReflexologyMassageMindfulnessAromatherapyPlease select the services that interest you

Would you be interested in CounsellingYesNo

Do you have a mental health diagnosis from a medical professional?YesNo

Mental Health Diagnosis

Consent

In order to help you we need to store information about you. Everything you tell us will be treated confidentially. Please tick the following statements to indicate your consent.

How would you like us to contact you?PhoneSMS (Text)EmailPostPlease select your preferred method of contact

Signature

Date

14/10/2024

You can withdraw your consent or change your mind at any time, but you must let us know in writing.

Equalities and Monitoring

We are required by our Funders to collect information for them relating to who is accessing our services. This information is fed back anonymously and is collected to ensure that the services we offer are accessible to all, and that we as a service provider take reasonable steps to ensure that our services are open to all.

Gender

Ethnicity

Age

Sexual Orientation

Religion