Warning, Javascript has been disabled, this form will not function correctly.
Date of Referral*
Who is this referral for?*
Details of Person Seeking Support:
First Name*
Surname*
Preferred Name (if different)
Date of Birth*
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
Email
If you have someone you would like us to contact in an emergency, please tell us their name.
Name of Emergency/Alternative Contact
Their telephone number
Their relationship to you (the client)
Your GP Surgery (if known, select from list)
Your NHS Number
How do you describe your gender?*
Please specify if not listed
How do you describe your sexuality / sexual identity?
Reason for Referral: How do you feel we 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.
Are there any other agencies involved in providing support to you? Please tell us about both current and past support.
Is there any other information that may be relevant to this referral?
Do you consider yourself to have a disability?
If yes, how would you describe this?
Is there any additional support that might be needed to access our services? (e.g mobility issues, wheelchair accessibility, alternative language etc)
Which service do you wish to access?
We offer face-to-face counselling and therapy services. Counselling is also available by telephone or using digital platforms. Some therapies are only available in limited locations.
Please indicate your preference from the list.*
Do you have a preference for a male or female counsellor?
Please note that although we will do our best to accommodate your preference, we may not always be able to do so.
Safeguarding: Please indicate any safeguarding issues based on recieved information, past history and your knowledge.
Have you ever had thoughts of, wanted to, or caused, any harm to yourself?*
Please tell us about this
Have you ever had anyone want to, or cause, harm to you? (this might be physical, emotional, mental or a combination)*
Have you ever had thoughts of, wanted to, or caused, any harm to others?*
Have you ever had thoughts of, wanted to, or caused, any harm to things like possessions or buildings?*
Do you, or have you ever used drugs?*
Do you, or have you ever used drugs?
Do you have a history of alcohol misuse? By this we mean regularly drinking more than the recommended amount*
Please tell us about any other risks you think we should know about, that are not covered by the questions above
If you are completing this form on behalf of someone else, please state below your name, agency/organisation and /or relationship to the individual.
Your Name
Your phone number
Job Title or Relationship to Client
Name of Referring Agency/Organisation
Your email address
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 strongly encourage you to discuss this with them
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 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?
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/
I confirm that I (the client) understand that the personal information contained in this form can be shared with Nottinghamshire Mind.*
I confirm that I (the client) understand and has agreed that the information relating to their health 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.*