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Date of Referral*
Details of Person Requiring Support:
First Name*
Prefers to be known as (If different)
Surname*
Date of Birth*
RIO Number
NHS Number*
Gender*
Preferred pronouns
Address line 1*
Address line 2
Address line 3
Town*
County
Postcode*
District*
Please ensure you provide at least one form of contact for the client.
Our preference is to use email for our formal communications where possible. If the client has an email address, and consents for us to use it, please ensure you include it here.
Client's Landline
Client's Mobile
Client's Email (If none, leave blank)
If the client has someone they are happy for us to contact if we can’t get hold of them directly, please tell us their name
Their telephone number
Their relationship to the client
GP Surgery (please select from list)*
Reason for Referral: Why are you referring the client for support?
Current presenting issues (please provide a short paragraph to describe the current situation)*
Mental health history relevant to this referral (Please provide a short paragraph to explain)*
If they have a formal diagnosis, please select primary – or most relevant – one
Other agencies involved in providing support to the client (either past or current)
Any physical health issues that we should be made aware of
Any other information that may be relevant to this referral
Safeguarding: Please indicate any safeguarding issues based on received information, past history and your knowledge
Risk to Self*
Details of Risk Identified
Risk from Others*
Risk to Others*
Risk to Property*
Details of any Other Risks Identified (not covered by the above)
Referrer’s Details
Your Name*
Job Title*
Which Team do you work for? e.g. Mansfield LMHT, Arrow Health PCN*
Which LMHT/CMHT do you work for?
Your email address*
Your phone number*
If we need to speak to you about this referral, what is the best time/day for us to contact you?
Is the client aware that a referral has been made to us? If they are not, we would encourage you to discuss this with them as soon as possible after submitting this referral.*
Contact Permissions and Consent
What is the best time/day for us to contact the client?
May we leave a message?*
May we say who we are if someone else answers?
May we leave a message if someone else answers?
May we send a text?
May we send an email?
May we send a letter?
What is the client’s preferred form of contact?*
Is there any additional support that the client might need to access our services? (eg mobility issues, wheelchair accessibility, alternative language etc)
Nottinghamshire Mind will store, process and use the information provided in this form to help us provide you with services and support. We will not share your data with other organisations or people without your permission. For more information, our privacy policy can be found on our website https://www.nottinghamshiremind.org.uk/policies-procedures/
By filling out this form you confirm that you have the client's consent to share their data with us. We are unable to receive referrals without the client's consent.
I confirm that the client understands and has agreed that the personal information contained in this form can be shared with Nottinghamshire Mind*
I confirm that the client understands and has agreed that the information relating to their health contained in this form can be shared with Nottinghamshire Mind*
I confirm that the client understands and consents to Nottinghamshire Mind storing and processing their information for the purposes of providing them with information, services and support.*