Referral Form

Referral Details – Required
This section contains all the required information we need to process a referral.

Date of Referral*

Referrer Full Name*

Referrer Email Address *

Referrer Phone Number*

Referrer Job Title*

Referrer Organisation*

How often would you like to be kept up to date on this referral? What are the best days and times to reach you?*

Client Title

Client Forename*

Client Surname*

Client Gender*

Client Address*

Client Postcode*

Client Borough

Client Email

Client Phone Number*

Client Preferred Method of Contact

At what times is the client generally available?

Client Date Of Birth

Client Ethnicity*

Client Ethnicity Further Details (e.g. Somali, Roma, etc.)

What level of English does the client have?*

Other languages spoken by client

Please state the reason for your referral. Please give as many details as possible.*

Urgency of Referral*

Will you be continuing to work with the client in future? Are there any other agencies involved in providing support to the client?*

Are there any other services listed above you feel the client would benefit from?

Does the client consent to MGWT making onward referrals to our VCS partners, so they can receive support?*

Additional Referral Questions – Optional
The following questions are all optional. This is our universal referral form for any professional to refer into our services, so we are aware many referrers will not have details on many of the areas below. We ask you to please provide as much detail as you can to support us in providing the best service we can for the client.

Does the client live with a long-term illness or health condition (physical or mental)? If so, please give details.

Has the client previously had involvement of mental health or other support services?

Does the client currently have a care package, and if so, with what agency?

What is the current residency status of the client in the UK?

How many people are in the household?

Who else is in the household? Please give (rough if necessary) ages and genders of any children.

Details of client's GP (name, address, telephone number)

Client emergency contact (name, relationship, contact details)

If you are making a referral for advocacy support, please add in any relevant details here, for example details of benefits receiving, NHS or NI number, etc.

Referrals to Starting Well services only

Named Health Visitor Or Team

If pregnant, what is the due date?

Named Midwife or Team

Where is the birth planned?

If applicable, please provide details of their partner, including name, contact details