Community Services Referral

Date of Referral*

Referral is for*

Which service is this referral for?*

If you wish to access more than one of our community services, please select ‘Well-Informed’ from the service options above, and our Recovery Coach will contact you to discuss this further.

Your Details / Details of Person Seeking Support:

First Name*

Name*

NHS Number, if known

Date of Birth*

Gender*

Address line 1*

Address line 2

Address line 3

Town*

County

Postcode*

District*

Please ensure you provide at least one form of contact

Landline

Mobile

GP Surgery (if known, select from list)

Reason for Referral: How do you feel our services could help?

Please tell us about the current issues or difficulties you are experiencing*

Please tell us if there is any mental health history relevant to this referral

Any physical health issues that we should be made aware of?

Is there any other information that may be relevant to this referral?

Is there any additional support that that might be needed to access our services? (eg mobility issues, wheelchair accessibility, alternative language etc)

Consent and Permissions

What is the best time/day for us to contact you (the client)?

What is your (the client’s) preferred form of contact?*

May we leave a message?*

May we send a text?

May we send an email?

May we say who we are if someone else answers?*

May we leave a message if someone else answers?

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 consent to share your data with us.

If you have made this referral on behalf of someone else: by completing this form, you are confirming that the client consents for their information to be shared with us. We are unable to receive referrals without the client's consent.

I confirm that I (the client) understand and agree that the personal information contained in this form can be shared with Nottinghamshire Mind.*

I confirm that I (the client) understand and agree that the health information contained in this form can be shared with Nottinghamshire Mind.*

I confirm that I (the client) understand and consent to Nottinghamshire Mind storing and processing my information for the purposes of providing me with information, services and support.*