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About You
First Name*
Last Name*
Preferred Name (if different)
Date of Birth*
Gender Identity
Phone Number*
Email Address*
NHS Number (if known)
GP Surgery*
Emergency Contact Name & Phone*
Address
Address line 1*
Address line 2
Postcode*
County*
Town / City*
Your Support Need
Have you ever, or are you currently, experiencing mental health difficulties?
Learning needs or support with reading/writing
Adjustments to help you take part
Any risks we should know about
Your Mental Health and Wellbeing
Medical conditions we should know about
If yes, please share as much or as little as you wish (optional)
In the last 3 months, what face to face appointments have you had with health professionals?
GP appointments
Number of contacts and reason for attending
Mental Health Nurse appointments
Social Worker appointments
Community Mental Health Team contacts
Number of A&E visits due to mental health
Have you had any hospital admissions for mental health
About Your Daily Life
Accommodation Type
Employment/Education Status
Do you consider yourself to have a disability?
Main Disability
Do you use any equipment or technology to help day to day?
Are you a Carer?
Do you have a Carer?
Equality and Monitoring
Ethnic Group
Sexual Orientation
Getting to Know You
How did you hear about us?
Referrer details
Is this a self referral?
Date of Referral
Name of Referrer/Keyworker if you have one
Job Title (Referrer/Keyworker)
Organisation (Referrer/Keyworker)
Telephone Number (Referrer/Keyworker)
Email Address (Referrer/Keyworker)
Do any of the following apply to you?
Have you been diagnosed with ADHD?
Are you an Asylum Seeker?
Have you been diagnosed with Autism?
Do you Care for a child with SEND?
Do you care for an adult?
Have you been diagnosed with early onset dementia?
Do you have a physical disability?
Do you have a sensory disability?
Do you have a mild to moderate learning disability?
Do you have a disability related to mental health?
Do you consider yourself to be from a minority ethnic background?
Are you currently experiencing homelessness?
Do you consider yourself to be part of the LGBTQIA+ community?
Do you have any long term health conditions?
Are you currently experiencing symptoms that your GP is investigating, but which do not yet have a clear diagnosis?
Do you have any mental health difficulties or conditions?
Do you have any neurodivergent conditions (e.g., ADHD, autism, dyslexia, dyspraxia)?
Are you a refugee?
Substance/alcohol misuse problems
Are you a veteran of the UK Armed Forces?
Do you have any unspent criminal convictions? Having a conviction will not necessarily stop you from volunteering, but will need to be taken into consideration when assessing your suitability. Please provide details
Declaration
Confidentiality at Trust Links & Agreement to Share Personal Information
If you would like a copy of the data entered on this referral form for your records, please enter your email address here